National Health Insurance Scheme
Healthcare
We were first introduced to the vision of transitioning Ghana’s paper-based claims processing system to a fully e-claims led system in 2011. The NHIA were looking for a partner who could consult them on how to effectively implement e-claims processing.
Healthcare e-claims Processing for the country of Ghana
The National Health Authority Ghana is a governmental organization responsible for the Ghanaian public’s health and welfare. This governmental organization is tasked with improving the access and management of health in Ghana, including the management of health electronic claims (e-claims). The National Health Authority set up the National Health Insurance Scheme (NHIS) as a social intervention program to provide financial access to quality healthcare for Ghana residents.
It starts with a vision
In 2011 the National Health Insurance Scheme (NHIS), an initiative within the Ministry of Health in Ghana had a vision – deliver seamless e-claims processing of health insurance claims. Along the way they hoped to become one of the leaders in Africa with such a solution. Fast-forward 11 years later and that vision is now a reality, but more on the results below.
We had our first meeting with representative of the NHIS to learn more about their vision and goals for e-claims processing. The state in 2011 was simple: everything was paper-based. NHIS knew all too well that paper-based was the past and that transitioning to e-claims was the future for their business. Now it was 2011 and Yameo was a company that had been on the market for just 5 years. In-house we had some experience with claims processing systems from our work with Dutch insurers and healthcare providers. However this would be one of our biggest challenges! And we really looked forward to it!
Understanding a new business culture
Until this moment Yameo had experience working with European-based organisations and so working in Ghana was our first big international step at the time. It was filled with interesting challenges, none more than understanding the new business culture. To better understand our new client we sent our Project Manager, Director and top developer to Ghana to meet with representative of the NHIS and immerse themselves into the work ethos, business culture and communication structure. That one week really laid the path forward for over 12 years of cooperation. To learn more about our our Discovery Workshops, read our dedicated page.
Gathering Requirements
We spent a good 2 weeks learning about their requirements for the solution. It was fascinating to learn that requirements were mainly driven by extensive research they had done on their market. We put everything down in one long list and started to prioritise requirements from there. This process was very pleasant as NHIS had already thought through which requirements they needed, we simply acted as a feedback partner here to think critically on some requirements, offer recommendations and provide answers to questions they had.
Let’s define the scope of e-claims processing!
We setup a 3-day workshop with the NHIS in Ghana to discuss the long list of requirements and how to prioritise them. We started by focusing on the end-users (healthcare providers) who would be creating e-claims to demand payment. They needed to have their own portal to upload claims and get fast feedback about the quality of delivered claims. Defined business rules would need to be written to validate claims, autocorrect if necessary and update prices to determine the payout. This meant:
- Backend system with system data backed-up, replicated and archived on a regular basis
- Web enabled – no download, keeping it easy to use
- Role based privileges for users
Moreover, the NHIS needed its own portal and dashboard to keep control and monitor in real-time the e-claims system and ensure quality. This again was based on privileges and roles to determine the right people had the right access.
Anti-fraud measures
Another important requirement was a built-in functionality to detect fraudulent claims. Since the NHIS is paying out validated claims they need to ensure fraud cases are minimised, yet extinguished. We built a special component based on business rules and updated over the years to include new technologies which was wildly successful in detecting fraudulent claims.
Business Rules Engine
We also had to build from scratch a business rules engine. We had done such development before but on a much smaller scale. To give you an example over one million lines of code were required here – a real credit to our .NET team at the time for undertaking and successfully developing a business rules engine of this size. It is really to their credit as the solution is still up and running today with exceptional results (see below).
More features
Such a unique client deserves tailored support
The vision NHIS had was to be a leader on the continent in healthcare e-claims processing and this requires a tailored approach to support, hosting and integration.
Integration
To start we needed to integrate the e-claims processing component with existing systems in the NHIS and Ghanaian government. To ensure seamless claims processing and control we worked with their team to make it happen.
Custom SLA
As we said in 2011 Yameo had been on the market for 5 years and working with such a big organisation in Ghana meant a custom approach. We opened a representative office in Accra, the capital and invested in a dedicated contact person for NHIS. Until today we have a dedicated team that supports their project.
Hosting by NHIS
A requirement was that NHIS will host the solution which meant we helped train their staff to manage and maintain the solution.
The Solution: E-claims Processing System
End-users use various public interfaces for claims processing. The solution is divided into sub-components whom each have their core function, such as report generation, credentialing, claims submission, etc. Each component runs on defined business rules set by the NHIA. The solution can process documents and detect fraud when it occurs.
The implementation of the system will reduce cost of generating claims and submitting them to the NHIA by service providers, as well as improve on their claims processing time.
Technologies we use
The Results
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