Factors Influencing Reimbursement of Hospital Financial Claims by Private Health Insurance Companies in Kenya

Abstract

Introduction: Despite the positive aspect of private health insurances, a number of challenges related to claims reimbursement for services offered to the insured have been raised. According to lean Six Sigma Improvement Project conducted in 2014 in a private hospital in Nairobi, Kenya, the top seven medical insurance companies that contributed to 40% of the corporate insurance business rejected over 4% of their total claims amounting to Kenya Shillings 214million over three years between 2011 and 2013. Even when claims are not disputed, the hospital usually experience delays in reimbursement sometimes up to 45 debtor days which is above the 30 days period stated on the contractual agreement. The broad objective of this study was to find out factors influencing payment of hospital claims by private insurance companies at a tertiary private hospital in Nairobi, Kenya. Specifically, this study sort to determine how hospital related factors, private health insurance related factors and insured related factors influence reimbursement of hospital claims by the private insurance firms. Methods: This was a cross-sectional research design using a semi-structured questionnaire to collect data.  Data was collected from 94 staff members who were initially stratified by job category and thereafter  randomly selected within each strata. Results: Hospital related factors positively and significantly influences the reimbursement of hospital claims by private insurance firms (r =.548, P < .001); (β₁ = .269, P < .001). Insurance related factors positively and significantly influences the reimbursement of hospital claims by private insurance firms (r =.385, P < .001); (β₂ = .226, P < .001). Insured related factors positively and significantly influences the reimbursement of hospital claims by private insurance firms (r =.273, P = .008); (β₃ = .245, P < .001). The value β₀ was also significant meaning that even without the three variables of interest in this study a certain minimum reimbursement will always exist. Conclusion: A continuous feedback to the employees on factors that hinder timely and full reimbursement and regular training of the employees on adherence to insurance protocol and guidelines will improve reimbursement rates. This will be further enhanced by Tailor-making the billing system to meet end users’ needs and having strategies on effective dissemination of information to the health providers and the insured clients, automation of claim processes, Continuous policy education to the insured and Stakeholders relationship to be enhanced.