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With the change over from the National Hospital Insurance Fund (NHIF) to the Social Health Insurance Fund (SHIF) less than one week away, CHAK member health facilities have raised concerns over lack of clarity on some operations of the new health financing scheme. The CHAK MHUs have also asked the Government to settle all their pending NHIF claims which run into millions of shillings.

In a meeting held last week with SHA, the CHAK member health facilities said they remained in the dark about fundamental operational issues of the fund including the contracting process, client registration, tariffs and claims system. The health service providers sought clarification on how the SHA referral system would operate as levels 4-6 health facilities were not allowed to receive walk-in patients under the new system.

The CHAK MHUs said they were unable to register patients in the SHA system and requested to be allowed to use portable devises to reach as many people as possible. Additionally, the health service providers sought clarification on the scope of emergency services to be offered by level 2 and 3 health facilities vis-à-vis those to be offered by levels 4-6 facilities under the new scheme, saying this was not clear.

Another question arose on when the health facilities would begin blocking patients on NHIF to SHA and exactly how the transition would happen. The SHA informed the health service providers that direction would be issued on the issue and transfer of patients from NHIF to SHIF would be seamless. It is worth noting that Kenyans are required to register afresh under SHIF although the deductions of 2.75 per cent of gross pay for salaried people are compulsory.

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Source: SHA presentation to CHAK MHUs by Dr Joyce Wamicwe 

 

During the meeting, the CHAK member health facilities were also briefed on expected digitization of the health sector. Although most Level 4-6 CHAK member health facilities have end-to-end health information systems and would most likely adapt well to a national system, few primary health care facilities (Level 2 and 3) are utilizing technology in health care. All health facilities in Kenya are required to have the web-based SHA portal by October 1, 2024, to facilitate claims processing after seeing patients. Digitization of Kenya’s health system has been provided for in the Digital Health Act 2023. Digitization would also ensure that health workers remained up to date with their licenses.

During several meetings with SHA, the CHAK member health service providers have consistently complained about long-standing NHIF payments, some of them several years old. The NHIF/SHA assured the health facilities that any NHIF payments not made by the roll over date of October 1, 2024, would be taken over by SHA. The CHAK member units asked SHA to issue them with a commitment letter, confirming the debts would be paid but were assured that all genuine pending NHIF claims would be honored by SHA.

The MHUs expressed concern at the time taken for claims to be moved from one stage to another in the NHIF system, saying some of the stages were taking an unnecessarily long time. Additionally, the CHAK MHUs said some claims were over seven years old and sought to know if these would be brought under SHA, urging their prioritization. Further, the CHAK MHUs pointed out that there were unable to view the status of their claims in the new SHA/NHIF system. The CHAK members demanded timelines for payment of the pending claims.

The MHUs added that pre-authorization for surgeries continued to take a long time, yet some patients required the service urgently. Some of the CHAK health facilities complained that they were unable to submit their claims to their local NHIF branches for processing as the system seemed to have a blockage.

In response, SHA told the meeting attendants that the blocked claims could be specific to certain NHIF branches and would be followed up once official complaints were received. Where the claims were already within the NHIF system, the CHAK MHUs were assured they had been captured as part of SHA debts and would be paid out.

Further, the CHAK MHUs were informed that it was impossible to view the stage at which their claims were in the new system. The CHAK members were asked to check for claims that had been returned but were yet to be acted on. It was noted that letters of claim rejection were yet to reach the health facilities in some instances and appeals could therefore not be lodged with SHA/NHIF.

SHA informed the CHAK health facilities that training on the use of its e-claim management system provider portal would be done beginning the third week of September 2024. The e-claims hardware would be provided by SHA.

SHA also informed the CHAK members that contracting would be done electronically and was anticipated to take a short time. Verification of data given during contracting would be done at a later date with consequences for fraud. The process of contracting would be continuous, giving service providers an opportunity to upgrade their services.

Under SHIF, empaneling of health service providers would being done by the Kenya Medical Practitioners and Dentists Council (KMPDC). A list of already empaneled health facilities was available on the SHA website. A total of 734 mission hospitals, both CHAK and KCCB, were already on the SHA list and empanelment was ongoing. The SHA pledged that SHIF tariffs wiould be gazzetted.

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