Abstract:

Background: Rejected medical claims pose a major challenge among National Health Insurance Fund (NHIF)-accredited healthcare facilities that provide healthcare services to National Health Insurance Fund beneficiaries. Identification of strategies utilized by healthcare facilities to mitigate rejected claims is key to the prevention of their occurrence to ensure sustained health services.

Methodology: This was a cross-sectional study design employing both quantitative and qualitative approaches to determine the patterns and mitigation strategies for rejected claims in the city of Mwanza. It was conducted between July 2024 and August 2024. The study population included all managers/claim officers and rejected claims from 46 health facilities. Quantitative data was entered into a computer using Epi-data version 3.1 and analyzed using STATA version 15. The Pearson Chi-square test was done and showed a significant link between the healthcare facility level and the number of rejected claim items and qualitative data was analyzed using thematic content analysis through NVIVO 12. Ethical approval and permission to conduct the study were obtained from relevant authorities.

Results: The data revealed significant variation in item rejection rates per claim across healthcare facilities ranging from 0.21 to 1.21 in zonal hospitals. At dispensary level, attendance date anomalies 14.8%, not indicated to diagnosis 7.36%, and item not claimed in physical form 4.12% were more common as compared to other facility levels. Non-adherence to Standard Treatment Guideline, improper dosage quantities, improper coding and wrong entry of the item were most frequently reported at polyclinics, accounting for 17.19%, 8.03%, 5.28%, and 9.29% respectively. Missing patient information/signature was more at health facility level 8.39%. At zonal level, duplicates, medicines/consumables already included in the package, and consultation charges not applicable to visit type were more common with 10.63%, 8.41%, and 42.66% respectively. The category of "Other reasons," which included different patterns such as invalid seal, invalid authorization number, alteration of admission dates and missing physical form, were overwhelmingly prevalent at regional facilities, which accounted for 22.68% in this category with the lowest at zonal level, 4.75%. Healthcare facilities implemented strategies such as immediate error verification, regular communication with National Health Insurance Fund, staff training, technology use, and internal audits to address the rejections. Despite these efforts, challenges persist, particularly those stemming from complex policies, which account for most rejections in facilities using online claim submissions.

Conclusion: Rejection patterns differ for health facility, with attendance date anomalies, non-adherence to Standard Treatment Guideline and National Health Insurance Fund pricing, and overutilization being the most common. Strategies to address the rejections should be tailored to specific health facilities.

Keywords: rejected claims, patterns of rejections, mitigation strategies for rejected claims.