The Ministry of Health (MoH) has unveiled plans to invest Sh5 billion in establishing a groundbreaking Centralized Healthcare Provider Management System (CHPMS) aimed at revolutionizing the administration of medical insurance claims under the proposed Social Health Insurance (General) Regulations, 2023.
In a regulatory impact statement accompanying the draft regulations, the MoH outlines the strategic move towards a single digital platform designed to streamline the lodging, validation, and payment of medical insurance claims.
This initiative is part of the broader social health plan that mandates a monthly deduction of 2.75 per cent from the income of Kenyans, contributing to a substantial annual fund of Sh133 billion.
"The proposed regulations envision the creation of a centralized digital platform accessible to empanelled and contracted healthcare providers for claims administration, recording beneficiary data, inputting healthcare service delivery data, and maintaining healthcare providers' data," asserts the Ministry of Health.
The CHPMS will play a pivotal role in the claims process by allowing hospitals to submit claims, review them for accuracy, validate the information, and facilitate timely payments.
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To safeguard against unauthorized access and ensure compliance with data protection laws, the system will grant user rights exclusively to authorized individuals.
Applicants seeking access to the system must align their requests with the Data Protection Act 2019 and the Digital Health Act, 2023.
Crucially, the CHPMS will integrate comprehensive data on beneficiaries, hospitals, and the services they offer.
This marks a strategic move by Kenya to counteract fraudulent activities within the medical insurance sector.
The system is designed not only to validate claims but also to maintain an audit trail of all processes, ensuring transparency and accountability.
The Ministry of Health estimates that the implementation of the CHPMS will result in a significant reduction of losses associated with fraud, projecting a decrease to between 10 per cent and 20 per cent of the total claims paid out.
This aligns with global trends, where errors and fraudulent activities typically account for 3 per cent to 15 per cent of total claim costs.
As Kenya takes this bold step towards modernizing its healthcare system, the CHPMS promises to be a game-changer in the fight against fraud, fostering efficiency, transparency, and accountability in the administration of medical insurance claims under the ambitious social health plan.
