Taking an Electronic Claims System from Pilot to Countrywide Implementation in Ghana

Abstract

This case study is about the challenges facing the Ghanaian National Health Insurance Scheme's claims management, how the processes of the e-claims system from 2010-13 were developed, and how the system bolstered efficiency in claims review and reimbursement, leading to lower claims costs through the detection of errors, abuse, and fraud. These efforts were led by the NHIS with support from the Ministry of Health, Ghana Health Service (GHS), service providers, and the World Bank’s Health Insurance Project (HIP). Despite the delivery problems encountered in technical, human resource, and financial matters, the NHIS effectively managed these challenges through evidence-based strategies. This enabled the NHIS to effectively use the e-claims system as a cost containment measure; the system enforced prescription and dispensing levels and linked treatment and diagnosis procedures. It also removed errors in claims processing and payment and minimized abuses of the system by detecting fraud. The e-claims system also provided information to the NHIS on the quality of health care provided and facilitated early payment of medical claims. In addition, it allowed the NHIS to extract credible claims data for analysis and overall policy direction.