Healthcare providers or medical facilities offering services under the new Social Health Insurance Act 2023 will be required to lodge payment claims to private insurers. Health Cabinet Secretary (CS) Susan Nakhumicha speaking at a past event. The government proposed changes to the Social Health Insurance Regulations 2024 to engage private insurers or claims agents. Private insurer’s role in new NHIF scheme In the new proposals, the claims agents will link hospitals and the Social Health Authority (SHA), which manages the new scheme. The changes require hospitals or health facilities to present claims to private insurers for payment review within seven days after discharging patients. Once the claim is reviewed, the insurer initiates payment from SHA or returns it to the health facility for correction in case of any errors. “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,” read the draft regulations as quoted by Business Daily. What will hospitals submit to private insurers? The contracted insurance agencies will require health facilities to submit the patient’s SHIF number, name, hospital registration number, and the amount claimed. The insurers will be required to be licenced by the Insurance Regulatory Authority (IRA) and have at least two qualified and experienced doctors to win the tender. The agencies will manage claim payments based on eight regions or zones. Facts about Social Health Insurance Fund (SHIF) In August 2023, President William Ruto’s Cabit repealed the National Health Insurance Fund (NHIF), replacing it with three funds, including SHIF. The Social Health Insurance Act 2023 directed mandatory registration of all Kenyans above 18 years of age to the Social Health Insurance Fund (SHIF). In January 2024, the Court of Appeal suspended the High Court ruling in November 2023, which barred the implementation of the Social Health Insurance Fund.
BY TUKO NEWS