NHIA sanctions 49 health facilities, 47 HMOs over service breaches
On Sunday, the National Health Insurance Authority announced that it had sanctioned 47 health maintenance organizations and 49 healthcare facilities in 2024 for violating its operational guidelines.
The authority's acting Director of Media and Public Relations, Emmanuel Ononokpono, signed a statement on Sunday stating that the main grievances against HCFs were the following: non-provision of payment narrations, denial of services, out-of-pocket payment for covered services, and lack of medication availability.
According to the report, the problems for the HMOs included refusals to monitor quality assurance in facilities, delays in settling agreed-upon reconciling payments, and delays or denials of referral authorization codes.
These are some of the highlights of the 2024 Annual Complaints Report, which was created by the NHIA's Enforcement Department under Acting Director, Enforcement, Dr. Abdulhamid Habib Abdullahi, according to the release.
The NHIA Act 17 of 2022, which mandates that NHIA set up procedures for receiving and addressing grievances from Schemes and Health Care Facilities, was followed in issuing the report.
Overall, 2929 complaints (84 percent), the majority of which were against HCFs, were settled out of the 3507 complaints that were handled during that time.
An analysis of the complaint distribution shows that 1232 complaints were made against HMOs and 2273 complaints were made against HCFs. Providers only filed two reports against enrollees.
Additionally, it stated that 12 HMOs were ordered to reimburse N748,200 to 15 subscribers, while 35 HMOs were given formal warnings.
“Based on the outcome of investigations, various sanctions were imposed on erring healthcare providers where indicated. Eighty-Four (84) formal warnings were issued to HCFs, while 54 enrollees received refunds of N4,375,500 from 39 HCFs.
“Four HCFs were suspended and six others were delisted. Also, 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,” the statement added.
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 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.
“The NHIA Complaint and Grievance Management Protocol establishes clear policies and procedures for complaint management and provides that complaints must be responded to in a timely manner. It also provides escalation procedures for complex or serious complaints,” it added.
Speaking about the change, NHIA DG Dr. Kelechi Ohiri explained that the agency's attempts to improve treatment quality, restore trust, and increase accountability naturally led to the creation of the complaints management mechanism. In the end, this will increase enrollment by motivating providers to provide current enrollees with higher-quality services.
"We will continue to do our best to ensure that enrollees receive the finest care possible," Ohiri stated. The penalties are intended to make it very evident that the NHIA will not put up with enrollees receiving subpar service.
"We applaud suppliers who are offering our enrollees top-notch services. They are deserving collaborators on our joint path to UHC. We anticipate that more, not less, will be done for patients as a result of the recent actuarially derived increases in capitation and fee-for-service payments to physicians, the first in 12 years. To cut down on care delivery delays, we must keep cooperating.
According to the authority, in addition to the punishments, it has implemented other procedures and released a circular requiring that referral codes for treatment be delivered within a one-hour window.
HCFs should start treating enrolled patients in accordance with the procedure set up to handle such circumstances if they do not hear back from HMOs within an hour.
In addition to providing a level playing field for all industry stakeholders, the report shows the Authority's dedication to openness, responsibility, and ongoing improvement in the delivery of healthcare services to beneficiaries. This can be found in furtherance of the vision of President Bola Ahmed Tinubu to make Universal Health Coverage a reality for all Nigerians,” he said.
