Guide · Uganda

Why your insurance claims get paid late

Insurers rarely refuse a legitimate claim outright. They query it. The claim goes back, someone at the clinic finds the file, fixes one line and resubmits — and the payment clock starts again. Three of those and a bill from March is settled in July.

So the money problem is usually not rejection. It is rework, and rework is caused by things that were decided at the desk during the visit, not in the accounts office afterwards.

What insurers say they need

The published requirements are strikingly plain. Liberty Health, for one, tells providers that claims must be clear, detailed and easy to read, that payment depends on correct information being supplied, and that claims must meet the insurer's submission cut-off times. That is the whole game: legible, complete, and on time.

The faults that cause most of the rework

Member details that do not match the insurer's record. A misremembered member number, a maiden name, a scheme that changed at the patient's employer. Caught at the desk this costs thirty seconds; caught at the insurer it costs a month.
Missing pre-authorisation where the scheme required it. The treatment was right and the claim is still going to bounce.
The co-pay collected wrongly. If the split was calculated by hand the patient may have paid too little or too much, and either way the claim and the receipt disagree.
Items the scheme excludes, billed to the insurer anyway — often because the person raising the claim did not know the exclusion.
Illegible or incomplete supporting paper. A prescription that cannot be read is a query. So is a claim whose items do not add to its total.
Submitted after the cut-off. The most avoidable of all, and the most common in facilities that assemble claims monthly from paper.

Build the claim during the visit, not at month end

Almost every fault above is cheap to fix while the patient is still in the building and expensive to fix afterwards. The practical rule is that a claim should be finished when the patient leaves, not started then.

Capture insurer, scheme and member number at reception, and keep them on the patient's record so a returning patient is not re-keyed.
Work out the co-pay at the cashier, per charge, so the patient pays the right amount and the insurer's share is fixed at the same moment.
Flag pre-authorisation and exclusions before the service is given, not after it is billed.
Keep an ageing list. A claim nobody is watching is a claim nobody is chasing, and insurers do not volunteer.
Record part-payments against the claim rather than treating the balance as a fresh debt.

What CareBoon does, and what it does not

The limit first, because it matters for how you plan: CareBoon does not submit claims electronically into an insurer's system, does not verify membership in real time, and no money passes through us — the insurer pays your facility directly, exactly as now. There is no unified claims exchange in Uganda that a small vendor can plug into and pretend otherwise.

What it does is remove the rework. Cover is attached at reception and remembered for the next visit. The co-pay splits itself per charge at the cashier, rounded so the patient never underpays, and excluded items can be marked so they are never billed to the scheme. Pre-authorisation is flagged while it can still be obtained. The insurer's share accumulates onto one claim as the visit moves, so the statement is complete the moment the patient leaves — printable, or emailed to the insurer's claims address. After that it is tracked, aged into buckets, and reconciled as payments arrive, including partial ones.

You still send it and they still pay you. What changes is that the claim leaving your facility is one they have no reason to send back.

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