The management of Nigeria’s Health Insurance Scheme (NHIS) said it has embarked on a reconciliation exercise to finally end “the disruptive contentions between Health Maintenance Organisations (HMOs) and Health Care Facilities (HCFs) over claims of unpaid bills, which have been known to result in in-service failure of the scheme”.
This exercise is part of a series of confidence building initiatives of the new Executive Secretary of the Scheme, Mohammed Sambo, a statement Thursday by the NHIS spokesperson, Ayo Osinlu, said.
The move came barely a year after the Nigerian senate gave the NHIS management three months to direct HMOs to settle all outstanding debt owed all healthcare providers in Nigeria.
Mr Osinlu’s statement said there has been “strident complaints” by hospitals over the failure of HMOs to effect payment of bills accruing from the care given to enrollees under NHIS, as well as other private insurance plans operated by HMOs.
“The need to address this as an urgency arises from reported cases of consequent service failure, whereby some facilities in the country are withholding care from enrollees over unpaid capitation and fee-for-service by HMOs, in spite of receiving funds timely from NHIS for those purposes”, the release noted.
Role of HMOs in NHIS
To deliver health services to enrollees (beneficiaries), NHIS deals with two major components: HMOs and healthcare providers (hospitals).
The HMOs are the go-between. They sit between the beneficiaries and the healthcare providers. They are the managers of the scheme’s funds.
HMOs are supposed to pay hospitals monthly for care provided to participants after collecting a quarterly upfront from the agency.
HMOs had operated largely without checks and reportedly received over N350 billion from the government in the 15 years of NHIS existence.
However, while coverage remained at barely 5 per cent, the few insured are complaining of not getting value for money.
They say the continued operation of HMOs was no longer needed following alleged mismanagement of funds paid to them since NHIS began.
Nonetheless, the NHIS management under Mr Sambo, a professor, opted for reconciliation exercise, “designed as a clearinghouse for areas of disagreement between HMOs and the facilities over unpaid bills”.
The process of the reconciliation exercise includes compulsory attendance by representatives of HMOs and HCFs, presentation and a careful review of claims and counter-claims, bank statements, contract documents, tariffs, and other relevant documents.
“Meanwhile, NHIS has directed that provisions of its Operational Guidelines which is the standard of procedure in the industry, must be strictly adhered to in the course of the exercise, while payment of agreed figures after the painstaking reconciliation must be effected by the HMOs concerned within two (2) weeks from the date of reconciliation”, the statement said.
Mr Osinlu said the reconciliation exercise, which is for a period of one month, began on June 15, and has been “reported to proceed smoothly and record impressive outcomes already, at the various NHIS offices in the states of the federation and the FCT where it is taking place.”