Patterns and Mitigation Strategies for Rejected Claims Among Health Facilities Providing Services for the National...

Background: Rejected medical claims pose a significant challenge for healthcare facilities accredited by Tanzania's National Health Insurance Fund (NHIF). Despite the NHIF's role in reducing out-of-pocket costs, claim rejections have been a persistent issue, largely due to documentation errors, coding mistakes, and non-compliance with NHIF regulations. This study determined the patterns of rejected claims and the strategies employed by NHIF-accredited hospitals to mitigate these challenges. Methodology: This cross-sectional study was conducted between July and August 2024 and used quantitative and qualitative approaches. The study utilized secondary data (August 2023 to January 2024) on the rejected claims from 46 healthcare facilities (HFs) and key informant interviews from the respective selected facilities. Descriptive data analysis was carried out using STATA version 15 and qualitative data analysis was conducted using NViVo2 version 12 software. Results: A total of 46 public (27) and private (19) HFs were included in this study. The data revealed significant variation in the average number of items rejected per claim across HFs, ranging from 0.21 in a regional referral hospital to 1.21 in a zonal hospital. Non-adherence to standard treatment guidelines (STGs) was significantly more common (p < 0.001) in polyclinics, accounting for 17.2% of the items rejected, and with the lowest number (0.8%) seen in zonal hospitals. Overutilization (drugs and investigations) was commonly reported in all HFs, ranging from 12.5% in polyclinics to 31.8% in district hospitals (p < 0.001). Non-applicable consultation charges were only reported in one zonal hospital. To mitigate these rejections, HFs implemented strategies such as immediate error verification, regular communication with NHIF, staff training, technology use, and regular supervision by the internal audit units. Despite these efforts, challenges persisted, particularly those stemming from complex NHIF policies, which account for most rejections in zonal health facilities. Conclusions: There are significant variations in rejection patterns among HFs, with attendance date anomalies, non-adherence to STGs, NHIF pricing, and overutilization being the most common reasons across all HFs. Strategies to address rejections should be tailored to specific health facilities, coupled with electronic systems that will detect errors during patient management.