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Hospitals bare weak points in chaotic SHIF transition
Health Cabinet Secretary Deborah Barasa converses with Mzee James Kanyore while undergoing dialysis at Sublime Healthcare in Nakuru Town on October 7, 2024.
Photo credit: Boniface Mwangi | Nation Media Group
Lack of formal training in pre-authorisation and claims management for surgical patients, as well as pre-approval for emergency and maternal health cases, are among the key factors holding back the ongoing transition from the National Health Insurance Fund (NHIF) to the Social Health Authority (SHA), a new survey among hospitals revealed.
The inaugural scorecard report, released by the Rural Urban and Private Hospitals Associations (RUPHA), shows that pre-authorisation is still disabled for most services, except renal services, and that the benefits list has not been fully uploaded.
The report highlighted SHA capitation, e-contracting, billing, and financial burden as the worst-performing sectors in the transition process.
These sectors scored 30 percent highlighting the need for urgent attention to ensure a smoother transition and continuity of care for patients.
The Status report provides an assessment of the ongoing transition from NHIF to SHA as of October 9, 2024, outlines the key issues being tracked, and assesses SHA performance on a scale of 0-100 percent, along with a grade (A-E) to reflect progress and effectiveness in addressing these issues.
“The transition has introduced several challenges in system access, claims processing, capitation, and financial management for healthcare providers. This assessment highlights areas of improvement and those requiring urgent attention to ensure a smoother transition and continuity of care for patients,” RUPHA chairman Brian Lishenga said.
The R This contradicts an earlier report from the SHA which claimed that 95 percent of problems had been resolved.
The website remains unavailable to all providers, affecting service delivery for all but those previously contracted to the NHIF, but not for non-NHIF providers.
About the capitation model, the technical working group has completed three out of 10 tasks, including setting up, drafting a proposal, and holding the first meeting. However, tasks such as identifying hospitals, redistributing patients, and disbursing funds are still outstanding.
In terms of billing and finances, the financial burden on hospitals continues as the joint committee set up on October 6 has yet to meet to address the challenges.
RUPHA has ranked registration, patient verification, and incorrect family member registration as average.
The report shows improvements in dialysis claims processing, but not for other services. Problems with billing and ICD-11 coding persist.
Providers with log-in credentials are able to bill for emergency and maternal health services. There are also concerns about system functionality, with some hospitals unable to access the system. In addition, technical difficulties are causing problems with patient premium payments, which could lead to lapses in coverage.
However, the report revealed promising progress on credentials and the system, with a score of 75 percent access, as most hospitals have received credentials.
Overall, the SHA's transition score stands at 42 percent, which puts it at a below-average level.
Earlier in the week, a survey conducted by the SHA's Engagement Forum on 7 October, which was designed to gather real-time feedback from providers on the progress of the transition, revealed that hospitals were experiencing difficulties logging into the system, pre-authorising claims and admitting patients.
The SHA Healthcare Providers Consortium survey shows that 64 percent of providers did not have credentials to log into the SHA system, meaning that none of the providers were able to visit and treat a patient in the new system.
The SHA has experienced challenges with its digital claims processing systems. As a result of these setbacks, providers had to resort to manually filling out claims forms.
This change was prompted by protests from providers who had difficulty accessing the system.
The SHA initially integrated two digital claims processing systems, apeiro from a subsidiary of an Abu Dhabi-based investment firm and eOxegen from India.
However, both systems failed to perform after the SHA went live on October 1. The latest system, developed by Savanna Informatics, also had security flaws, highlighting significant problems with the security of Kenyans' contributions.
