The Social Health Authority (SHA) on Tuesday addressed public concerns following reports of inconsistencies in oncology pre-authorization approvals.
The authority clarified that its automated system follows strict benefit rules, with variations in approvals reflecting patients’ unique clinical needs rather than preferential treatment.
SHA emphasized transparency, safeguards, and ongoing improvements in cancer care.
It affirmed that all cancer-related pre-authorizations are handled via a fully automated digital system, designed to operate in accordance with the benefit limits, access rules, and tariffs established under Legal Notice No. 56 (LN 56).
This system automatically generates approvals based on predefined criteria, with individual staff members having no capacity to arbitrarily adjust approvals.
The authority explained why approvals might vary between patients, even when they share broad diagnoses such as breast cancer.
It noted that clinical profiles, diagnostic needs, and treatment pathways are rarely identical among patients, due to factors including the extent of prior benefit utilization, the stage of care, whether diagnostic, active treatment, or follow-up, as well as clinical complexity and the nature of the pre-authorization request submitted by healthcare providers.
SHA highlighted that patients have the freedom to choose any cancer facility contracted by SHA, and that the variation in approvals is a reflection of the system applying uniform benefit rules to differing clinical circumstances rather than any form of preferential treatment.
Regarding financial aspects, SHA emphasized that oncology diagnostics and claims reimbursement are based on uniform, gazetted tariffs that apply equally across public, private, and faith-based facilities.
These tariffs are publicly available on the SHA website, ensuring fairness, transparency, and sustainability of the health insurance pool.
Addressing concerns about possible interference, SHA reiterated its strict stance, saying it does not condone, permit, or tolerate preferential access to benefits based on personal influence or connections.
The digital pre-authorization system includes real-time utilization tracking and audit trails to prevent duplication, inappropriate use of benefits, or unauthorized interference.
The authority urged the public to report any credible allegations of system manipulation to [email protected] for investigation.
In an effort to improve cancer care equity and sustainability further, SHA revealed plans to integrate National Cancer Control Programme (NCCP)-aligned clinical pathways into the pre-authorization workflow.
This enhancement aims to support more standardized diagnostic panels, ensure clearer provider submissions, and deliver an improved patient experience.
SHA concluded by reaffirming its commitment to transparency and public engagement, encouraging beneficiaries and the wider public to seek information or clarifications through SHA’s official channels.
These include SHA offices across all counties, Huduma Centre desks nationwide, as well as email and toll-free phone contacts for general and media inquiries.
The authority's communication reaffirms its dedication to maintaining fairness in access to oncology benefits while continuing to refine the pre-authorization process to meet patients’ needs effectively.
