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In a continued push to improve the quality of healthcare delivery under its supervision, the National Health Insurance Authority (NHIA) has sanctioned 49 healthcare facilities (HCFs) and 47 Health Maintenance Organisations (HMOs) for various infractions in 2024.
The sanctions, issued in line with the Authority’s operational guidelines, followed investigations into complaints from enrollees under both state and national health insurance schemes.
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A statement signed on Sunday by NHIA’s Acting Director of Media and Public Relations, Emmanuel Ononokpono, revealed that key complaints against healthcare facilities included the unavailability of medicines, denial of services, out-of-pocket charges for covered services, and failure to provide payment narrations.
For HMOs, infractions included delays or denials in issuing referral authorisation codes, delayed settlement of reconciled payments, and failure to conduct quality assurance checks in contracted health facilities.
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“These are some of the highlights of the 2024 Annual Complaints Report produced by the Enforcement Department of the NHIA under Acting Director, Enforcement, Abdulhamid Habib Abdullahi,” the statement noted.
The report, issued in line with the NHIA Act 17 of 2022, reflects the agency’s mandate to establish mechanisms for handling and resolving complaints from enrollees and service providers.
The health agency said 3,507 complaints were handled during the period, out of which 2,929 (84 per cent), majority of which were against HCFs, were resolved.
“A breakdown of the distribution of complaints reveals that 2273 were reports against HCFs, 1232 were against HMOs. Only two reports were recorded against enrollees by providers,” it said.
Breakdown
The scheme said based on the outcome of investigations, various sanctions were imposed on erring healthcare providers where indicated.
It said 84 formal warnings were issued to HCFs, while 54 enrollees received refunds of N4,375,500 from 39 HCFs. Also, four HCFs were suspended and six others were delisted.
The statement also indicates that 35 HMOs got warning letters and directives to institute corrective actions while 12 HMOs were directed to refund a total of N748,200 to 15 enrollees.
According to the report, in 2024, all complaints were fully investigated and responded to within the standard response time of 10 to 25 days.
It said the average complaint resolution time for complaints that required investigation was 15 days. The complaints resolution rate (within the timeline) was 84 per cent.
“Where issues could not be resolved within the timelines an explanation was provided to complainants while the resolution process continued. The complaints received in 2024 were submitted through the following routes: in-person, written letters, email, telephone, the NHIA call centre and other channels,” it said
“The NHIA Complaint and Grievance Management Protocol establishes clear policies and procedures for complaints management and provides that complaints must be responded to in a timely manner. It also provides escalation procedures for complex or serious complaints.”
Speaking on the development, the director general of NHIA, Kelechi Ohiri described the authority’s complaints management process as organic to the agency’s efforts to enhance accountability, rebuild trust and improve quality of care.
Mr Ohiri said this will ultimately drive higher enrolment by encouraging providers to offer current enrollees an enhanced quality of service.
“Enrollees deserve the best care, and we will continue to do our best to ensure they get it. The sanctions are meant to send a clear message that the NHIA will not tolerate substandard service for enrollees,” he said.
He commended providers who deliver high quality services to enrollees, noting that they are worthy partners in our collective journey towards UHC.
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“With the recent actuarially derived increases of capitation and fee-for-service payments to providers, the first in 12 years, we expect more to be done for patients, not less. We must continue to work together to reduce delays in receiving care.”
The authority stated that it has also put additional policies in place beyond the sanctions and issued a circular mandating a limit of one hour for issuance of referral codes for treatment.
It said if HCFs do not get a response from HMOs within an hour for enrolled patients, they should commence treatment based on the protocol established to deal with such situations.
“The report demonstrates the commitment of the Authority to transparency, accountability, and continuous improvement in the provision of healthcare services to beneficiaries as well as provide a level playing ground for all stakeholders in the industry.”
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