NHIA sanctions 49 healthcare facilities, 47 HMOs over poor performance, breaches

AKOR SYLVESTER, Abuja

In it’s determination to improve the quality of service to enrolled Nigerian patients, the National Health Insurance Authority (NHIA) said it sanctioned 49 erring healthcare facilities (HCFs) and 47 health maintenance organizations in 2024 in accordance with its operational guidelines.

The action, it said, followed investigations into complaints received from patients enrolled in the state and national health insurance schemes.

Key issues recorded in the complaints against HCFs, according to the authority, were: unavailability of medicines, denial of services, out-of-pocket payment for covered services and non-provision of payment narrations.

For the HMOs, the issues related to delays or denials of referral authorization codes, delays in settlement of agreed reconciled payments, refusal to monitor quality assurance in facilities etc.

According to the statement signed by the Acting Director of Media and Public Relations of NHIA, Emmanuel Ononokpono, these are some of the highlights of the 2024 Annual Complaints Report produced by the Enforcement Department of the NHIA under Acting Director, Enforcement, Dr Abdulhamid Habib Abdullahi.

The Report was issued 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.

In all, the statement said, a total of 3507 complaints were handled during the period, out of which 2929 complaints (84%), the majority of which were against HCFs, were resolved.

It stated that 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.

Based on the outcome of investigations, it said 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.

According to the report, in 2024, all complaints were fully investigated and responded to within the standard response time of 10 to 25 days.

The average complaint resolution time for complaints that required investigation was 15 days. The complaints resolution rate (within timeline) was 84%.

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 center and other channels.

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, 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.”

Ohiri added: “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 actually 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”.

Beyond sanctions, NHIA has also put additional policies in place. The NHIA has also issued a circular mandating a limit of one hour for the issuance of referral codes for treatment.

If HCFs do not get a response from HMOs within 1 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 providing a level playing ground for all stakeholders in the industry.

This is in furtherance of the vision of President Bola Ahmed Tinubu to make Universal Health Coverage a reality for all Nigerians.