Unpaid wages: NHIS moves to resolve HMOs, hospitals’ feud
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.
The HMOs were
largely blamed for the scheme’s poor performance, prompting calls – from both
the health ministry and NHIS workers – for their removal.
They say the
continued operation of HMOs was no longer needed following alleged
mismanagement of funds paid to them since NHIS began.
Reconciliation
Exercise
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.”
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