The government plans to contract private medical insurance providers and claim settling agents to review and process claims under the planned Social Health Insurance Fund (SHIF) in which the State is eyeing Sh133 billion in premiums annually.
The draft Social Health Insurance (General) Regulations, 2024 published last week shows the insurers and claims settling agents will be the link between hospitals and Social Health Authority —the entity that is going to manage three funds, replacing National Health Insurance Fund (NHIF).
The insurers and the agents will be receiving claims from healthcare providers and reviewing the claims. Claims approved will then be forwarded to the authority for payment while erroneous or incomplete ones will be returned to hospitals for correction.
“A healthcare provider or health facility shall, within seven days from the date of discharge of the patient, lodge a claim to the claims management office or a medical insurance provider and claim settling agent, where applicable, for review and processing of the claim,” reads the draft regulations in part.
The arrangement presents a new business for private medical insurers and agents given that currently, NHIF is the one that collects premiums and receives and reviews claims for settlement for the millions of customers under the national health cover.
The government has chosen this arrangement in a bid to speed up the claims management process, which has been problematic under NHIF, with many hospitals complaining of delays in receiving payments when they lodge claims.
“This presents a new business for commercial medical insurers and claims settling agents. NHIF has been processing and settling claims of all medical insurance claims. So if the authority is going to outsource, it certainly presents a new business,” said Tom Gichuhi, chief executive at the Association of Kenya Insurers.
Mr Gichuhi does not expect the coming in of the social healthcare insurance to hurt the private insurance business since the proposed 2.75 percent deductions on gross pay is employee-based and is not expected to hurt employers’ financial position to support the medical covers of their workers.
Hospitals will be required to submit to the contracted insurers and agents details such as the social health insurance number of the patient, the name of the patient and their hospital registration number and amounts being claimed.
The medical insurance providers and claims settling agents will be required to be registered by the Insurance Regulatory Authority, have a valid licence and have at least two qualified and experienced medical doctors. They will bid for this role and be selected on a competitive basis.
The regulations have not specified the number of insurers or agents it will contract but says these entities will manage the claims in zones. No medical insurance provider and claim settling agent will be assigned to more than one zone.
The draft has proposed eight zones, which have been categorized based on population size, disease burden, the geographical size of the area and the estimated claims as informed by existing records and data.
