Rural and Urban Private Hospitals (RUPHA) has pointed out the shortfalls of the new health insurance system, the Social Health Authority (SHA), following its official rollout on October 1.
RUPHA in its report on Thursday October 10 stated that the transition has introduced several challenges in system access, claims processing, capitation, and financial management for healthcare providers.
The status report provides an evaluation of the ongoing transition from the National Health Insurance Fund (NHIF) to SHA as of 9th October 2024.
“The report outlines key issues being tracked and scores SHA’s performance on a scale of 0-100%, along with a grade (A-E) to reflect progress and effectiveness in addressing these issues,” RUPHA said.
“This assessment highlights areas of improvement and those requiring urgent attention to ensure smoother transition and continuity of care for patients.”
RUPHA Outlines SHA Shortfalls
Login Credentials and System Access
RUPHA reported that by October 9, most hospitals had received their credentials, while some were still awaiting them.
The SHA received a score of 75 percent (Good) and a grade of B.
Claims Submission and Management
According to RUPHA, dialysis claims processing has shown improvement; however, the same cannot be said for other medical services.
Healthcare providers continue to face challenges with billing and ICD-11 coding, which remain significant hurdles.
As a result, this aspect of SHA’s performance received a score of 50%, categorizing it as average, and earning a grade of C.
Also Read: SHA Lists Contracted Hospitals for Cancer Treatment & Dialysis; How to Check
Preauthorization Processes
The preauthorization processes have seen minimal progress, as they remain disabled except for renal services.
Healthcare providers are restricted to the limited procedures and benefits currently available, and the benefits list has not been fully uploaded.
This has contributed to a score of 40%, indicating below-average performance, and a grade of D.
Patient Verification and Registration
It was revealed that there are ongoing issues with registration, patient verification, and incorrect family member registration persist.
Score: 50% (Average), grade: C
Capitation Model
Rupha mentioned that the technical working group has accomplished three out of ten tasks, that is setting up, creating a draft proposal and first meeting. Pending items include identifying hospitals, patient redistribution, and disbursing funds.
Score: 30% (Poor), grade: E
Billing and Financial Strain
The Private hospital stated that a joint committee was set up on 6th October, but it is reported that it has not yet met to address funding issues as financial strain on hospitals persists.
Score: 20% (Poor), Grade: E.
System Functionality and Location-Related Errors
In the report, RUPHA reported that the location data errors have continued to prevent some hospitals from accessing the system.
Score: 40% (Below Average), grade: D
Also Read: What Salaried Kenyans Will Contribute Monthly and Annually to SHA
Handling of Emergency and Maternal Health Cases
In these services, it was alleged that providers with log in credentials can claim for these services but are limited by the procedures available, and preauthorization remains disabled.
Score: 50% (Average), grade: C
Patient Premium Payment Issues
The hospitals also revealed that ongoing technical difficulties are preventing patients from paying premiums, risking coverage lapses.
Score: 40% (Below Average), grade: D
Training for Preauthorization and Claims Management
The private hospitals disclosed that there is no formal training that has been provided by SHA, particularly for preauthorization and claims submission for surgical patients.
Score: 30% (Poor), grade: E
Electronic Contracting (e-contracting)
RUPHA disclosed that as of 6th October, the e-contracting portal was accessible to most previously NHIF-contracted providers, but not to non-NHIF-contracted providers.
At the same time, less than 10% of providers were able to complete e-contracts due to site bugs.
“While SHA reported on 8th October that 95% of the issues were fixed, the site remains unavailable to all providers, impacting service provision,” RUPHA added.
Score: 30% (Poor), grade: E
RUPHA noted that the final score for the SHA transition stands at 42%, reflecting below-average performance.
Follow our WhatsApp Channel for real-time news updates
https://whatsapp.com/channel/0029VaB3k54HltYFiQ1f2i2C
