Impact Of Claims and Reimbursement Verification on Healthcare Service Delivery: The Case Of NHIS Monitoring Visit to Healthcare Provider Sites in the Upper West Region

Abstract

In the absence of any form of health insurance, out-of-pocket payment for health care lead to a decreased utilization of health services and catastrophic health expenditures. National Health Insurance has been promised financial model for both informal and formal sectors to reduce these problems in many countries. In Ghana, the quality of Ghanaian people lives has increasing improved in general due to the implementation of a robust National Health Insurance Scheme (NHIS). However, in Ghana, fraud in health insurance claims has become a significant problem whose rampant growth has deeply affected the healthcare deliveries. The challenges health insurance schemes faced on claims fraud cannot be overstated. The purpose of the current study was to critically assess verification and re-imbursement of claims, highlighting its contribution to healthcare service delivery in the Upper West Region. The study is grounded on the theory of change and the agency theory. Through a mixed method using a sample size of 132 respondents, it was found that in claim verification and reimbursement men were dominant and a majority of them have formal education and have worked for 3 to 11 years. The results further established that verification of claims processes and tools were strictly adhered by all the health facilities in the Upper West Region. It was also established that claims verification exercise has both positive and negative impact on healthcare service deliveries. The findings established that inadequate resources, training, logistics and financial penalties were the major barriers affecting verification exercises. It was concluded that there is a significant relationship between quality care service delivery and claims verification and reimbursement. It therefore recommended that the NHIA should review staff training, resource its offices and intensify claims verification exercises and sensitize healthcare providers and the insured on healthcare utilization.