The Social Health Authority has given several hospitals 15 days to share documents verifying over Ksh3 billion worth of claims flagged by the Authority.
In a statement on Monday, September 15, the Authority stated that claims were flagged due to several reasons, the top of which was the fact that a majority of the claims needed additional information.
"As part of the routine claims adjudication exercise, SHA has flagged over 3 billion worth of claims that require more documentation to assist the review teams to adjudicate the claim," a statement signed by SHA CEO Mercy Mwangangi read.
Claims are typically flagged when they lack some essential supporting documents, including the mandatory itemised invoice, a filed claim form and a discharge or case summary. Claims missing these and other supporting documents will henceforth be subjected to new procedures.
According to the Authority, this new system was a way to ensure transparency and curb fraud within the government healthcare system, which has been marred by controversy in recent months.
To this effect, starting September 16, SHA will activate a Missing Documents Resubmission Module on the provider portal. This feature will allow healthcare providers to respond directly within the system to simplify the process of correcting incomplete claims.
Once notified, providers will have a 14-day window to resubmit the missing documents, and a countdown timer will be set in motion, indicating the time remaining for each claim. The timer will be visible to healthcare providers to remind them of the urgency of the matter.
Importantly, the system will preserve all original submissions such that providers cannot delete or replace documents which have already been uploaded. All they can do is add missing information as specified in the notes attached to each claim.
In addition, patients will also receive alerts about the need for claim resubmission to ensure transparency and keep them informed about their claims' status.
With this system, quick action will be of the essence, as claims not submitted within 14 days will automatically transition to the 'rejected' status. Hospitals have until September 30, and after this date, claims with incomplete documentation will no longer be eligible for processing.
For the step-by-step guide to assist providers with the new system, SHA has made the manual available on its official portal to ensure smooth compliance.
In addition to the new system, SHA also announced that there would be routine surveillance activities by county health teams starting Tuesday, September 16. During these visits, service providers are encouraged to cooperate fully.
