From Fred Ezeh, Abuja
National Health Insurance Authority (NHIA) has announced that 49 healthcare facilities and 47 Health Maintenance Organizations (HMOs) have been sanctioned for breaching its regulations as contained in its operational guidelines.
NHIA said the complaints against the healthcare facilities consist of unavailability of medicines, denial of services, out-of-pocket payment for covered services and non-provision of payment narrations, while the HMOs had cases relating to delays or denials of referral authorization codes, delays in settlement of agreed reconciled payments, refusal to monitor quality assurance in facilities etc.
Emmanuel Ononokpono, Acting Director, Media and Public Relations, NHIA, in a statement, on Sunday, said the punitive actions followed successful investigations into the complaints received from patients enrolled into the state and national health insurance schemes.
He said: “These are some of the highlights of the 2024 annual complaints report produced by the enforcement department of the NHIA under Acting Director, Dr. Abdulhamid Habib Abdullahi.
“The report was in compliance with the NHIA Act 17 of 2022, which requires NHIA to establish mechanisms for receiving and resolving complaints by members of the schemes and health care facilities.
“A total of 3, 507 complaints were handled during in the period under review (2024), out of which 2, 929 complaints (84%) were resolved. A breakdown of the distribution of complaints revealed that 2, 273 were reports against healthcare facilities;1, 232 were against HMOs, while two reports were recorded against enrollees by providers.
“But based on the outcome of investigations, various sanctions were imposed on erring healthcare providers where indicated. 84 formal warnings were issued to healthcare facilities, while 54 enrollees received refunds of N4,375,500 from 39 healthcare facilities.
“Four healthcare facilities 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 report further indicated that in 2024, all complaints were fully investigated and responded to within the standard response time of 10 to 25 days. It added that the average complaint resolution time for complaints that required investigation was 15 days.
“The complaints resolution rate (within timeline) was 84 per cent, and 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 in-person, written letters, email, telephone, the NHIA call center, and other approved channels.
NHIA Director General, Dr. Kelechi Ohiri described the NHIA’s complaints management process as organic to the agency’s efforts to enhance accountability, rebuild trust, and improve quality of care. “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.
“We commend providers who are delivering high-quality services to our enrollees. They are worthy partners in our collective journey towards UHC. 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”.
He confirmed that a circular has been issued mandating a limit of one hour for issuance of referral codes for treatment, and if healthcare facilities do not get a response from HMOs within one hour for enrolled patients, they should commence treatment based on the protocol established to deal with such situations.
“However, the report demonstrates the commitment of the NHIA 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.
“This is in furtherance of the vision of President Bola Ahmed Tinubu’s vision to make Universal Health Coverage (UHC) a reality for all Nigerians,” he added.
He further confirmed that the NHIA Complaint and Grievance Management Protocol had established a clear policies and procedures for complaints management, and also provides that complaints must be responded to in a timely manner, with escalation procedures for complex or serious complaints.