44pc of healthcare providers yet to streamline NHIF claims
Dr Brian Lishenga (centre), Chairman of the Rural and Urban Private Hospitals Association of Kenya (Rupha) leading his members in addressing journalists at Boulevard hotel in Nairobi on December 16, 2024.
An estimated 44 percent of healthcare providers contracted by the Social Health Authority (SHA) are yet to complete the reconciliation of National Health Insurance Fund (NHIF) claims, a survey has revealed, hindering accurate tracking of liabilities and delaying reimbursements.
A study conducted by the Rural Urban and Private Hospitals Association (Rupha), in collaboration with the Kenya Association of Private Hospitals, the Christian Health Association of Kenya, the Kenya Conference of Catholic Bishops, and the Kenya Healthcare Federation, examined payment disbursement and the financial health of health facilities.
The SHA, which is now responsible for managing claims, was tasked with reconciling and processing payments for claims from October and November 2024.
The survey conducted between December 24 and 31 in 243 facilities found that the reasons for delays in reconciliation varied across the Kenya Essential Package for Health (Keph) levels.
Many level 5 facilities cited ongoing efforts as the main reason for their incomplete reconciliations, indicating that the reconciliation process is still ongoing.
Level 3 to 5 facilities reported challenges in working with SHA branches, where staff may be uncooperative or lack the necessary knowledge to assist.
"A significant number of tier 4 facilities identified lack of access to the NHIF claims portal as a major barrier, while lost claims data was a less common issue across all tiers. Among smaller facilities in tiers 2 and 3, lack of awareness of the reconciliation process emerged as a key barrier, highlighting the need for improved communication and training," the survey said.
The survey further revealed a discrepancy in the payment of arrears from the defunct NHIF. About 49 percent of facilities reported not receiving payments during the period under review, while 40 percent confirmed receiving payments and 11 percent were unsure whether their payments were for arrears.
In October last year, the government committed to settling the Sh30 billion owed to hospitals by the NHIF, a move seen as crucial to maintaining the trust and cooperation of these facilities under the Social Health Insurance Fund (Shif).
As of November 15, the Ministry of Health announced that the SHA had disbursed Sh5 billion to providers across the country, with an additional Sh2.5 billion to be released in the last week of the same month, adding that the remaining payments would be made in phases, depending on the availability of funds.
The report also shows that 56 percent of health facilities have completed the reconciliation process, highlighting the need for improved collaboration between health providers and SHA offices.
Faith-Based Organisation (FBO) facilities show variable completion rates under the Keph. All level 6 facilities reported 100 percent completion, while level 5 facilities achieved 75 percent.
At level 4, only 42 percent have completed reconciliation, and at level 3 it's 31 percent. Level 2 facilities reported the lowest completion rate at 25 percent.
"This trend suggests that higher tier facilities are more successful due to better resources, while lower tier facilities struggle with limited resources and access to historical NHIF claims data," the report said.
Private health facilities generally outperformed FBOs, with all private facilities in tiers 5 and 6 reporting 100 percent completion. Level 4 had a 60 percent completion rate, Level 3 had a 59 percent completion rate and Level 2 had a 58 percent completion rate.
Despite improved performance, private primary care facilities still face reconciliation challenges, particularly at lower levels. Larger facilities benefit from greater resources and better engagement with SHA offices, while primary care facilities face systemic issues, including limited access to tools and knowledge of the reconciliation process.
"Improved communication, targeted training, and access to reconciliation tools for smaller facilities, together with increased support from SHA offices, can help resolve outstanding claims and improve services at all levels of care," the report said.
