The government is allocating a substantial Sh5 billion towards the establishment of a cutting-edge digital platform dedicated to streamlining the processing of medical insurance claims. This initiative falls under the ambit of the social health plan, a compulsory program poised to collect significant contributions from Kenyan citizens each month.

In the newly disclosed draft Social Health Insurance (General) Regulations for 2023, the Ministry of Health (MoH) outlines its intention to introduce the Centralised Healthcare Provider Management System (CHPMS). This innovative system is designed not only to facilitate the seamless lodging of claims by hospitals but also to play a pivotal role in reducing instances of fraud.

Hospitals will leverage the CHPMS to submit claims for patient treatments, and the system will subsequently review and validate these claims, expediting the payment process. The funding for this ambitious healthcare plan is set to come from Kenyan citizens, with a mandated deduction of 2.75 percent from their monthly income, contributing a substantial Sh133 billion annually.

According to the MoH, the proposed regulations emphasize the establishment of a centralized digital platform accessible to empanelled and contracted healthcare providers. This platform will serve multiple functions, including claims administration, recording beneficiary data, inputting healthcare service delivery data, and maintaining healthcare provider information.

“The system will grant user rights to authorized individuals, and applications for access will align with the Data Protection Act of 2019 and the Digital Health Act of 2023,” states the Ministry of Health.

The comprehensive nature of the CHPMS will encompass beneficiary data, as well as information about hospitals and the services they offer. This move is a proactive measure to curb fraudulent activities within the realm of medical insurance. Additionally, the system will maintain a meticulous audit trail of all processes and boast robust data retrieval capabilities.

The Ministry of Health estimates that the implementation of the CHPMS will significantly mitigate losses associated with fraud, potentially reducing them to a range of 10 to 20 percent of the total claims disbursed. This aligns with global estimates, which suggest that errors and fraud collectively contribute between three and 15 percent of claim costs.

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