Influence of Provider Ownership on Insurance Claims Performance: A 12-month retrospective comparative analysis of KSCHMA accredited public and private facilities in Kano State, Nigeria
This 12-month retrospective study of KSCHMA-accredited facilities in Kano State, Nigeria, reveals that provider ownership significantly influences claims performance, with public facilities demonstrating higher approval rates and fewer denials or queries compared to private facilities, even after adjusting for confounding variables.
Original paper licensed under CC BY 4.0 (https://creativecommons.org/licenses/by/4.0/). This is an AI-generated explanation of the paper below. It is not written or endorsed by the authors. For technical accuracy, refer to the original paper. Read full disclaimer
Health insurance is a promise: when you fall ill, a pool of money pays for your care so you do not have to pay the full bill yourself. For this promise to hold, the system needs a reliable way to check that the care was real, necessary, and priced correctly before releasing the funds. This checking process is called claims management. It is the administrative bridge between a patient receiving treatment and a doctor or hospital getting paid. If this bridge is shaky, with too many errors or delays, the entire system can stall. Hospitals may run out of cash to buy medicine, and patients may be asked to pay out of their own pockets, defeating the purpose of the insurance. In many places, these checks are done by comparing the paperwork submitted by the clinic against a set of rules. The speed and accuracy of this paperwork determine whether the system works smoothly or grinds to a halt.
In Kano State, Nigeria, a specific agency called the Kano State Contributory Healthcare Management Agency manages this process for both government-run hospitals and private clinics. A recent study looked closely at how well these two different types of facilities handled the paperwork over a single year. The researchers wanted to know if the fact that a hospital is owned by the government or by a private business changes how quickly and successfully their bills get approved. They examined every electronic claim submitted between August 2025 and July 2026, a total of more than 30,000 records. This was not a small survey; it was a complete look at the actual administrative work done by 50 different facilities.
The results showed a clear difference between the two groups. The government-run facilities were more successful at getting their claims approved. About 92 percent of their claims were approved, while only about 88 percent of the claims from private clinics were approved. This gap might seem small, but in a system handling thousands of bills, it represents a significant number of rejected requests. The private clinics also had more claims that were stuck in limbo, waiting for a decision, and more claims that were sent back for corrections. When the researchers looked at the reasons for rejection, they found that private clinics were more likely to make specific mistakes, such as choosing the wrong code for a medical procedure or charging the patient incorrectly. The most common reason for rejection for both groups was simply missing or unclear documents, but the private sector struggled more with the technical details of coding and billing.
Speed was another area where the government facilities pulled ahead. On average, it took two days for a claim from a public facility to be reviewed and decided upon, whereas private facility claims took four days. The time it took to receive the final payment advice was even more telling. Public facilities waited about 63 days for this confirmation, while private facilities waited about 81 days. This delay is critical because hospitals need cash flow to operate. The study found that the type of facility mattered even after accounting for other factors like the size of the hospital or whether the patient was in an emergency. Claims from private facilities were significantly less likely to be approved than those from public ones, suggesting that the ownership model itself is linked to how well the paperwork is prepared.
The researchers also noticed that the system faced a bottleneck toward the end of the year. A large number of claims piled up and remained pending between May and July 2026. This accumulation made it look like approval rates were dropping during those months, but the data suggested this was simply a delay in processing rather than a sudden increase in errors. The study also found that claims that were submitted correctly the first time were far more likely to be approved than those that had to be sent back and resubmitted. This highlights that the initial quality of the paperwork is the most important factor in getting paid.
The authors conclude that the difference in performance is not just about who owns the building, but about how the work is done inside. Private clinics, driven by the need to maximize revenue, may sometimes over-report services or make billing errors that lead to rejections. Public hospitals, while facing their own bureaucratic challenges, seem to have more stable processes for documentation and coding. The study suggests that to fix these issues, the insurance agency should not just penalize mistakes but provide targeted help. This could include better training for private clinic staff on how to fill out forms correctly and using digital tools to catch errors before a claim is even sent. By improving the quality of the paperwork, the system can ensure that money reaches the providers faster, keeping the promise of health insurance alive for everyone.
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