The Social Health Authority (SHA) has resorted to manually filled out claim forms by healthcare providers after its digital claims management system (CMS) suffered a series of setbacks.
The CMS, a digital database for processing and contributions, has bumped into hitches since August prompting SHA to integrate different systems in a race against time to meet the October roll-out.
A communication seen by the Business Daily showed that SHA has resorted to manual claim forms amid relentless failures on the CMS platform.
The three-page Healthcare Providers (HCPS) form template consists of several sections, including healthcare provider and patient details and SHA healthcare benefits, which healthcare providers will complete manually on behalf of patients.
“Please use capital letters and tick the appropriate boxes. Submit this form with supporting documents within seven (7) days from the discharge date. All fields in this form are mandatory. Incomplete forms will not be processed,” the manual form provided by SHA said.
Acting SHA CEO Elijah Wachira did not respond to text messages and a call by the Business Daily for comment on the latest development.
Insiders said the manual forms will be used as a stop-gap measure as SHA races to smoothen the glitches on the CMS.
The present CMS database was developed by Savanna Informatics and is the latest of three claims systems being tested, all of which have experienced problems since August, exposing a major gap in the security of millions of Kenyans’ contributions.
The SHA first integrated apeiro, a subsidiary of an Abu Dhabi-based investment firm, and eOxegen from India, which failed to deliver after the SHA’s October 1 launch, before turning to the one developed by Savanna Informatics, which also revealed gaps.
The shift to manual claim forms follows protests by healthcare providers who were unable to access the CMS.
A survey conducted by the SHA’s engagement forum on October 7, to gather real-time feedback from providers on the progress of the transition, revealed that hospitals are experiencing difficulties logging into the system, pre-authorising claims, and admitting patients.
The SHA Healthcare Providers Consortium survey shows that 64 percent of healthcare 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 survey results also show that no Level 1,2 and 3 hospital is mapped to Primary Care Network Level 2 (PCN 2) and none have been able to verify patients.
The forum includes members from the SHA, private and faith-based organisations, including SHA Chairperson Abdi Mohammed, SHA Director of Beneficiary and Provider Management Hazel Koitaba, a SHA board member representing providers, and the SHA Director of Benefits and Claims Management.
Other organisations involved are the Kenya Association of Private Hospitals (KAPT), the Rural and Urban Private Hospitals Association of Kenya (RUPHA), the Kenya Healthcare Federation (KHF), the Kenya Conference of Catholic Bishops (KCCB), and the Christian Health Association of Kenya (CHAK).
According to health providers, the Ministry of Health wants hospitals to treat patients first and then submit claims, which they say will worsen the situation with outstanding bills.
“There’s a precedent here where hospitals lost a lot of revenue during the biometric transition, and millions of shillings lost have not been paid so far,” said a doctor who spoke on condition of anonymity because he was in a position to disclose the information.
The change also comes hours after the public sector unions have since threatened to take industrial action in the next 14 days if the government fails to address the challenges reported by Kenyans and various stakeholders regarding the implementation of the SHA.
The unions, led by Kenya Medical Practitioners, Pharmacists and Dentists Union (KMPDU) secretary general Davji Attelah, accused the government of failing to resolve the crisis affecting access to healthcare.
They highlighted that the transition from NHIF to SHA has created significant challenges for civil servants, public sector workers, and the general public.
According to Mr Attelah, the government’s hasty implementation of the SHA has slowed access to health services previously available to NHIF cardholders, without clear communication about what the SHA would provide.
“The SHA deducts more from workers’ salaries but provides less. This is unacceptable as workers are paying more for inferior services and their wellbeing is at risk. With the cost of living rising, the SHA is putting an unnecessary financial burden on families,” he said.
The union leaders also claimed that the transition from the NHIF to the SHA has threatened the jobs of those employed under the old health scheme, creating additional insecurity.
“We are also calling for a 100 percent transition of previously employed NHIF staff with full benefits. If these concerns are not addressed within 14 days, the public sector unions will have no choice but to proceed with industrial action,” the statement read in part.
