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TRAINING REPORT ON HEALTH INSURANCE CLAIMS MANAGEMENT

FOR PHARMACISTS, ACOUNTANTS, AND CLAIM MANAGERS HELD AT


THE CAPITAL VIEW HOTEL KOFORIDUA.
13TH TO 14TH MAY 2010.

INTRODUCTION:
Health insurance is a mechanism of spreading of risk of incurring
health care cost over a group of individuals or households. It can also be
stated as a means of financial protection against the risk of unexpected and
expensive illness.
The idea of quality health for all Ghanaian citizens started immediately
after independence in 1957 with the free medical care. This could not be
sustained because of economic recession in 1970s and early 1980s. Then
came in was the User Fees popularly known as the Cash and Carry in
1983.This however had its own problems ranging from, barrier to accessing
basic health care, poor and other vulnerable groups denied access to basic
health care.
The national health insurance scheme was established under Act 650, LI
1809 of 2003 by the Government of Ghana to provide basic health care
services to persons resident in the country. The Law allows three (3) types of
insurance in Ghana. They include the District Mutual Health Insurance
Scheme, Private Commercial Health Insurance Scheme and the Private
Mutual Health Insurance Scheme.
The District Mutual Health Insurance Scheme is the only one that receives
support from Central Government. The National Health Insurance Authority
(NHIA) is mandated to regulate the operations of District Schemes in
Ghana.
Claims can be defined as a statement that something is true although it has
not been proved and other people may not agree with or believe it (Oxford
Dictionary.)

OPENING:
The two day workshop on Health Insurance Claims Management was
chaired and opened by Mr. Aggrey, the Head of Regional Pharmacy
Department. In his address, he reminded participants of the importance and
relevance of the workshop. He stated that, the Health facilities specifically
the hospitals were loosing so much money .This he said was due to the
fraudulent nature of service providers. He added that, the National Health
Insurance Scheme would collapse if care was not taken.
He urged participants to take the workshop seriously and participate
fully. He it was the only way they can change the situation for the better.

OBJECTIVES:
The objectives of the workshop were as follows;
1. Manage claims effectively.
2. Adhere to standards in treatment and management of medical
conditions.
3. Reduce mistakes and intentional misconduct in the processing of
claims.
4. Avoid the motivations towards fraud and other criminal acts.

5. Reminded that wrong processing can cost your facility heavily.


6. Agree in solidarity to make the NHIS functional to give us a
unhindered access to good quality health care.
7. Minimize challenges in the processing of claims to reap the maximum
benefit therein.
Some expected outcome of the workshop by participants included the
following:
• To be able to manage claims effectively.
• To be able to reduce mistakes in the processing of claims.
• To be able to avoid the motivations towards fraud and other
criminal acts.
• To be able to learn to minimize challenges in the processing of
claims to reap the maximum benefits.
• To be able to impact the knowledge acquired to other
colleagues who could not benefit from the workshop.

METHODOLOGY:
• Presentation and questions
• Discussion
• Practical
• Group work

TRAINING:
In all, eleven (11) sessions were treated for two days. These
included the following,
Day 1
1. Objectives
2. Background/Introduction (History of Health Insurance)
3. Tariffs and GDRG
4. Claims Management 1
5. Claims Management 2
6. Discussions
Day 2
7Abuse and Fraud in Claims
8. Health Data and Claims Management
9. Claims Management Unit Set Up
10.Regional Hospital Presentation
11.Group Work Presentation and Discussions

DISCUSSION:

The definition of Health Insurance was given as a mechanism of spreading


of risk of incurring health care cost over a group of individuals or
households. The definition of Claim was also given as a statement that
something is true although it has not been proved and other people may not
agree with or believe it. The history of Health care financing in Ghana was
recalled and participants were taken through the various health care
financing systems, starting from the free medical care to the User fees or the
Cash and carry systems of 1983.
Participants were taken through on the effective management of claims.
It was said that effective management of claims was important to sustaining
the National Health Insurance Scheme. Also participants were advised to
adhere to standards in treatment and management of medical conditions. It
was said that it was the only way to give quality health care to the people.
Participants were taught what fraud and the various types of fraud
found in the National Health Insurance Scheme. Some motivators of fraud
were taught to participants. It was said that, the education of clients, training
of providers on GDRG and potential sources of abuses and fraud, timely and
orderly presentation of claims for vetting by providers among others were
some of the ways to prevent fraud. Also it was said that public and private
cooperation against fraud is essential.
Participants were advised to reduce the mistakes and the intentional
misconduct in the processing of claims. It was said that, the claims forms
must be seen as bank checks and must be handled and filled with accuracy.
Participants were shown samples of claims forms and together with the
facilitator identified the mistakes. Participants were reminded that wrong
processing of claims forms can cost their facility heavily. It was said that
accurate processing of claims forms will help reap the maximum benefits.
A question was asked on which policy is banning medical assistants
from handling chronic diseases. It was explained that the medical assistants
were only trained to handle primary diseases. A concern was raised about
the claims form. It was said that it should be redesigned. A question on what
happens to principal diagnosis which does not conform with the drugs in the
facility. It was said that severe malaria and any other disease must be treated
as such with the right therapy.

There was a practical session where participants were taken to the


regional hospital to know what goes on at the National Insurance Unit.
Participants were taken through on how to accurately complete a claim form.
After that participants were put into small groups of ten (10). Each group
was assigned to find the mistakes in a completed form. There was also a role
play or case for each group to solve.
EVALUATION OF THE TRAINING PROGRAMME:
For the purpose of evaluating whether the trainees had gained from the
training imparted to them, each participant was given an evaluation form to
complete.

TOPICS:
On the topics treated by facilitators, 98% of participants said it was good and
2% mentioned that it was fair.

EDUCATIONAL ASPEECTS:
Almost (100%) of participants said the training objectives were met.
About (98%) said the programme met their personal objectives.
More than ninety percent that is, (98%) said the training methods used
were good while the remaining two percent (2%) said the methods used
were fair.

RELEVANCE TO WORK:
Almost (100%) of the participants said the content of training was relevant
to their present profession.

SOCIAL ASPECT/ ADMINISTRATION:


Majority, (80%) acknowledged that, the reception on was good whiles
(20%) said was fair.
Almost 100% of the participants said the conference room was spacious
enough.

CLOSING:
The regional director of health in the person of Dr Erasmus E.A. Agongo
who closed the workshop emphasized on the need to share knowledge
acquired with other colleagues as they go back to their facilities to change
the situation for the better.
He said Ghana had made a great move in going for the National Health
Insurance. He added some nations had used ten (10) and some hundred (100)
years to make it work and was optimistic that the National Health Insurance
will workout. He added that to him the National Health Insurance was a
Salvation to Health care.
He mentioned that fraud was not new and that the focus should be on
the goal. He added that anything deviating from the goal was Health
Insurance. He however lamented about people not reflecting on what they
themselves had done wrong but instead they pointing hands at what others
had done.
He mentioned that accreditation was critical for quality health care but
quick to state that it was rather too strict on some facilities. He added that
facilities must be provided with certain standards and left to operate instead
of stopping them. He added that grass root facilities must be supported. He
mentioned that communities in which the National Health Insurance was
operating should be brought on board and get them involved.
Finally, he commended participants for time and patience for the two
days intensive workshop and reminded to put he knowledge and skills
acquired into good use.

CONCLUSION:
The training programme ended successfully with participants sure of going
back to implement the knowledge and skills acquired.

ACKNOWLEDGEMENTS: