Operational Factors Related To Performance of Health Facilities in Implementing National Health Insurance Fund Online Claims Management Information System

Abstract

Background information: Claims Management Information System is an interconnected modular information system for claim processing and reimbursement transaction introduced by NHIF. It enables a health facility to determine the eligibility of the beneficiary to particular insurance, authorize, approve, submit claims online, track and verify the status of claims, avoid duplication, and timely reimbursement. However, there has been slow adoption of Online CMIS in health facilities and the operational factors related to the implementation of the system have not been explored. Main study Objective: This study aimed to explore operational factors related to the performance of health facilities in implementing online CMIS. Methods: Exploratory Cross-sectional study design was employed and data was collected by using in-depth interviews between November and December 2020. A total of 15 participants were purposively selected from three health facilities and interviewed using a structured interview guide. Data collected were analyzed thematically by transcription, translation, coding, sub-themes, and themes. Results: Results revealed that implementation of online CMIS facilitates timely claims submission and reimbursement, reduced workload, administrative costs, claims rejections, and fraud in studied health facilities. Availability of ICT infrastructure such as computers, software, HMIS, office space, skilled It personnel, top management support, staff engagement in decision making, were the enablers for the early adoption and implementation of online CMIS. Participatory decision-making, regular training sessions, and seminars to build the capacity of staff engaged in the implementation of online claims management information system were also key factors in the implementation of the online claims submission system. Conclusion: The online claims submission system improved revenue collection as well as timely reimbursement in the studied health facilities. However, the implementation and adoption to be successful depended on the interplay of facility capacity and adoption strategies employed and resources saving benefits of the system.