Board pledges reimbursement for health insurance

Kathmandu, July 2: The Health Insurance Board (HIB) has requested associated health centres to not suspend the services under health insurance scheme, assuring that the board would provide reimbursement at the earliest.

Recently, major tertiary hospitals have been expressing inability to continue providing services under the scheme, citing that they have not received reimbursement for the services they have provided.

Tribhuvan University Teaching Hospital (TUTH), on June 18, had announced a plan to postpone services under the scheme from June 29. The reason behind the decision was the economic burden for the institution as they were not receiving timely reimbursement from the board.

However, issuing a notice on June 29, the TUTH informed that they would continue the services as the HIB wrote a letter saying that it would reimburse the insurance amount claimed by the hospital.

Meanwhile, Dharan-based BP Koirala Institute of Health Sciences (BPKIHS) has also sought to postpone the scheme. Citing that the board has failed to reimburse Rs. 340 million to the BPKIHS, the institution will be suspending services under the scheme from July 4.

According to the HIB officials, most individuals enrolled in the scheme seek referral from their primary health centres as they lack even basic health services.  

Among 3,000 patients who visit BPKIHS daily, the institution informed that half of the patients come with referral under the health insurance scheme.

“The main source of income of the BPKIHS is the fee charged for the treatment of the patients. However, we have not received our invested money from the HIB. It has affected salary and allowances of health personnel,” said Dr. Gyanendra Giri, vice chancellor of BPKIHS.

As per the BPKIHS, they have not received 70 per cent of the claimed amount from the HIB.

The TUTH and BPKIHS are tertiary health centres of the country. An individual enrolled in the health insurance scheme has a primary health centre listed as his/her first point of visit. If the required service cannot be availed from the first point of visit, the individual is referred to a tertiary health centre.

Doctors also informed that the health insurance scheme has reduced the stress of out-of-pocket expenditure among public, leading sick individuals to health centres for timely treatment. Recently, around 5.639 million individuals have enrolled in the health insurance scheme from 746 local levels of 77 districts.

A total of 450 health centres provide services under the scheme. They provide services to the insurers and send the information of availed services to the HIB as a claim for reimbursement. The HIB analyses and confirms the claims and reimburse the money.

“There has been a delay in confirming the claims that has prevented us from reimbursing money to health centres in time. We receive around 25-30,000 claims daily,” said Dr. Damodar Basaula, executive director at HIB.

Until a week ago, the HIB had reimbursed Rs. 8.13 billion to health centres on the basis of 5,284,894 claims within the current fiscal year 2021/22.

“We had unconfirmed claims from previous fiscal as well. We completed all the former ones. Until May 29 of the current fiscal year, we still had 1,853,953 claims to confirm,” read a statement by the HIB on June 23.

Dr. Basaula also informed that they had to confirm the claims cautiously as they have received several fake and illogical claims. “We are also trying to form and implement a digital system which would confirm claims effectively and timely. We are also going through the claims. The board is still strengthening itself,” said Dr. Basaula.

Until the board is equipped with enough manpower and infrastructure and budgets, the HIB has requested the health centres to not postpone services under the scheme. “We have also requested the BPKIHS to not postpone the services. We have kept their claims in priority and will provide their money soon,” said Dr. Basaula.