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Background: Rejected medical claims pose a significant challenge for healthcare facilities accredited by Tanzania’s National Health Insurance Fund (NHIF). Despite the NHIF’s role in reducing out-of-pocket costs, claim rejections have been a persistent issue, largely due to documentation errors, coding mistakes, and non-compliance with NHIF regulations. This study determined the patterns of rejected claims and the strategies employed by NHIF-accredited hospitals to mitigate these challenges. Methodology: This cross-sectional study was conducted between July and August 2024 and used quantitative and qualitative approaches. The study utilized secondary data (August 2023 to January 2024) on the rejected claims from 46 healthcare facilities (HFs) and key informant interviews from the respective selected facilities. Descriptive data analysis was carried out using STATA version 15 and qualitative data analysis was conducted using NViVo2 version 12 software. Results: A total of 46 public (27) and private (19) HFs were included in this study. The data revealed significant variation in the average number of items rejected per claim across HFs, ranging from 0.21 in a regional referral hospital to 1.21 in a zonal hospital. Non-adherence to standard treatment guidelines (STGs) was significantly more common (p < 0.001) in polyclinics, accounting for 17.2% of the items rejected, and with the lowest number (0.8%) seen in zonal hospitals. Overutilization (drugs and investigations) was commonly reported in all HFs, ranging from 12.5% in polyclinics to 31.8% in district hospitals (p < 0.001). Non-applicable consultation charges were only reported in one zonal hospital. To mitigate these rejections, HFs implemented strategies such as immediate error verification, regular communication with NHIF, staff training, technology use, and regular supervision by the internal audit units. Despite these efforts, challenges persisted, particularly those stemming from complex NHIF policies, which account for most rejections in zonal health facilities. Conclusions: There are significant variations in rejection patterns among HFs, with attendance date anomalies, non-adherence to STGs, NHIF pricing, and overutilization being the most common reasons across all HFs. Strategies to address rejections should be tailored to specific health facilities, coupled with electronic systems that will detect errors during patient management. Full article

Background: Puerto Rico (PR) has experienced significant demographic changes, characterized primarily by an aging population and an unprecedented exodus of medical doctors. Ophthalmologists are of particular concern as they commonly serve older populations, and the island has high rates of some age-related eye diseases in the United States (US). Our research aims to investigate the factors driving ophthalmologists in PR to emigrate to the mainland US. Methods: This is a cross-sectional study among ophthalmologists in PR, using survey data collected from May to June 2023. This study recruited a convenient sample of all ophthalmologists practicing in PR via outreach in person and online communities. The survey covered various types of challenges faced by ophthalmologists, their demographics, and practice details. STATA/BE 18 statistical software was used for data analysis. Statistical tests, such as chi-square and proportion tests, were performed, stratifying results by age, gender, subspecialty, geographic health districts, experience, and practice type. Results: Among 130 of the estimated 218 ophthalmologists in PR, insurance/billing issues were identified as the primary challenge to practicing in PR and the primary reason to leave PR. The challenges that were identified included required authorizations for patient care, unjustified claim rejections, and threats of contract cancellation. We found that new ophthalmologists (≤15 years of practice) faced more specific challenges than experienced ophthalmologists (>15 years of practice), such as difficulty in obtaining insurance contracts. Conclusions: Insurance/billing issues are a pervasive concern for ophthalmologists in PR. New ophthalmologists are disproportionately affected by these challenges, potentially leading some to find employment outside of PR. There is a need for targeted policies—regulation of insurance contracting and increased reimbursement from private insurance plans—to reduce insurance contracting barriers for keeping a sustainable physician workforce in PR. Full article