Private hospitals decry delays in processing of claims under SHA

Rural and Urban Private Hospitals Association of Kenya (RUPHA) is now calling on the government to address delays encountered in either approving or paying claims.

Rupha told MPs that most of their facilities have been hugely affected by the incessant delays especially under the Social Health Authority (SHA).

Appearing before the National Assembly’s Health Committee, the association disclosed that 53 per cent of their dues have been pending because of the delays.

Rupha chairman Dr Brian Lishenga did not however disclose the amount owed to them due to delays in approval of claims.

Of particular concern to the group is the delay in receiving responses in claims, which they say is being done by third party, whom they have a challenge in accessing, since it is outsourced.

“We are experiencing challenges in handling of claims because it is being done by a third party to the extent that if a hospital has an issue, it does not know who to contact because it is outsourced. When you have claims pending, you hardly get the answers and 90 per cent of those made have not been paid. We ask the committee to help us entangle the claims management,” Lishenga said.

Lishenga also raised alarm that the Universal Health Coverage now stands at risk owing to issues ranging from financial shortfalls, opaque systems and weak implementation.

The committee chaired by Seme MP James Nyikal has been meeting private and Faith-Based Organisations on the implementation of UHC, transition to SHA and other policy issues.

Lishenga sought intervention of the committee on the need to unlock UHC through digital health, saying that there should be a hybrid digital health architecture.

“We support a national strategy that blends the strengths of SHA provider portal model with those of Integrated Health Technology Systems, ensuring compliance, innovation and provider autonomy,” Lishenga said.

The association also rooted for a structured accreditation framework, adding that the Digital Health Agency (DHA) should be mandated to accredit health vendors based on clear, published criteria such as biometric validation capacity so that local and established vendors can participate.

Rupha also pushed for SHA to adopt machine readable rules with version controlled benefit packages, preauthorisation logic and policy change documentation to prevent billing confusion and compliance ambushes.

They said that Section 35 of the Social Health Insurance Fund (SHIF) Act calls for the establishment of Claims Management Office, which should be responsible for among other roles reviewing, processing and validating medical claims from healthcare providers and healthcare facilities.

The system is also tasked with appraising medical claims based on the benefit package, issuing pre-authorisations for access to healthcare services based on the benefit package, developing an e-claims management system and establishing systems and controls for detecting and identifying fraud appropriate to the Fund’s exposure and vulnerability among others.

INSTANT ANALYSIS

Faith-based healthcare organisations in Kenya have been raising concerns about significant delays in the processing and payment of claims by the Social Health Authority. These delays are causing financial strain on the facilities, impacting their ability to provide essential healthcare services. They are demanding that the government address these issues promptly and settle outstanding debts, with some organisations threatening to halt services if their demands are not met.