Assessment of Community Based Health Insurance Claim Reimbursement Practices and Challenges, the Case of Federal Hospitals in Addis Ababa, Ethiopia.

Abstract

Background of the study: Community-based health insurance (CBHI) scheme is a powerful tool to achieve universal health service coverage by providing financial protection against healthcare costs. Ethiopia introduced CBHI, although its utilization is suspected to be poor. However there is no documented study so far on the practices and challenges of CBHI claim reimbursement for service provided by Ethiopian Federal Hospitals. It is the reason why this study became area of interest. Currently one the major internal revenue for Health facilities is a reimbursement claim collected from CBHI schemes of the country. Due to claims payment delays, the Federal hospitals are also suffering from the stock out of medicines and laboratory tests. Objectives: The general objective of the study was to assess the current practices of claim reimbursement for service provided by Federal Hospitals and challenges faced in the processes of reimbursement. To assess the duration of claim reimbursement process in Federal Public Hospitals. To identify factors affecting claim reimbursement process in Federal Public Hospitals. In addition, it was to assess the rejection rate of claim of CBHI service in Federal public Hospitals. Methodology: A cross-sectional study was used to assess the current practices and challenges of claim reimbursement of the health care services to the beneficiaries of CBHI. The study was conducted from June 01, 2024 to July 30, 2024 on the purposively selected organizations and Individuals: EHIS director, Addis Ababa City CBHI service leader, EPSS Finance director, CEOs of Federal Hospitals found in Addis Ababa, Pharmacy service directors the selected hospitals and CBHI officers of these hospitals, in Addis Ababa City Administration, Ethiopia.