Health Insurance Board Faces Budget Gap and Operational Delays
Kathmandu – The Health Insurance Board has yet to clear payments totaling Rs 16.45 billion to healthcare institutions by end of Falgun (mid-March). Despite the mounting dues, the board had only Rs 1 billion in its account during the same period.
Currently, 485 health institutions are providing services under the national health insurance scheme. These include 404 government-run facilities, 33 community hospitals, and 48 private institutions. Board Director Dr. Raghu Kafle stated that, with ongoing claims and service utilization, its total payment obligations could reach Rs 24 billion by the end of the fiscal year.
So far, the government has released Rs 7.5 billion to the board—less than one-third of the expected requirement. According to officials, this shortfall is affecting timely payments to service providers and may impact financial management if not addressed.
According to Dr. Kafle, operational inefficiencies have added to the board’s challenges. Although it receives 30,000 to 40,000 payment claims daily, it can verify only around 7,000 due to limited manpower and outdated claim review systems. As a result, a massive backlog of around 9 million unverified claims has built up by Falgun end (mid-March).
Part of the delay is linked to the limited use of electronic systems. Many service providers are not yet submitting real-time claims or uploading billing details digitally. Additionally, the board’s current workforce—26 permanent and 22 contract employees—is not sufficient to manage the growing volume of claims.
Other concerns include the absence of clear criteria for reviewing claims and limited adoption of automated systems. Some claims have been found to include services outside the insurance scope, adding to the verification burden.
The board has stated that addressing these issues will require additional budget, increased technical capacity, and improvements in internal systems to ensure efficient processing and timely payments going forward.