Implementation of national health insurance claims process management in regional Referral hospital a case of Temeke regional referral hospital Tanzania

Abstract

Background: In 2001, Tanzania started implementing a National Health Insurance Fund (NHIF) Scheme. Through the NHIF Claims Process, services rendered by providers could be reimbursed by the Scheme. In 2012 NHIF established an electronic claims processing system ensure an effective implementation of claims process. Despite such efforts, there is limited information about the service providers’ compliance with claims preparation procedures at the health facility level. Essentially, there is little documentation on the implementation of the NHIF claims process management, especially at regional referral hospitals in Tanzania. Objective: To assess the implementation of the National Health Insurance Fund claims process management in Temeke Regional Referral Hospital. Materials and Methods: This study employed qualitative case study design to assess the implementation of the NHIF claims process in Temeke regional referral hospital. A purposive sampling method was used to select participants in this study following the principle of saturation level of the information collection. NVivo 12 software was used to code the data into themes for thematic analysis. Results: This study found that the NHIF claims process management is implemented according to NHIF guideline and service providers were aware of the claims mangment. However, there were several critical challenges that hinder effective implementation of the claims process management. They include noncompliance to claims and submission process, electronic claims system challenges and a discrepancy between NHIF treatment manuals and the national standard treatment guideline. Conclusion: Although service providers are aware of the NHIF claims preparation and submission procedures. The noncompliance to claims management is the challenge, which negatively affects the provision of high-quality health services to clients insured under the NHIF. Recommendation: The noncompliance practices to the NHIF claims management among health service providers has a negative impact on the provision of quality health services to NHIF clients and performance of the NHIF scheme. Thus, an effective collaboration among key stakeholders is necessary in order to address the noncompliance practices in the context of collective improvement of health service delivery.