THE National Health Insurance Authority (NHIA) has sanctioned 49 healthcare facilities (HCFs) and 47 Health Maintenance Organisations (HMOs for violating its operational guidelines.
This was revealed in a statement on Sunday, June 30, by NHIA’s spokesperson, Emmanuel Ononokpono.
According to the statement, the key issues recorded in the complaints against HMOs were denial of services, out-of-pocket payment for covered services, non-provision of payment narrations and unavailability of medicines.
For the HMOs, the issues were related to delays or denials of referral authorisation codes, delays in settlement of agreed reconciled payments, refusal to monitor quality assurance in facilities, among others.
The statement highlighted key findings from the NHIA’s 2024 Annual Complaints Report, produced by the Enforcement Department under Acting Director, Enforcement, Abdulhamid Habib Abdullahi.
The NHIA issued the report in compliance with its Act, which mandates it to establish complaint resolution mechanisms for scheme members and healthcare facilities.
“In all, a total of 3507 complaints were handled during the period, out of which 2929 complaints (84 per cent), the majority of which were against HCFs, were resolved.
“A breakdown of the distribution of complaints reveals that 2273 were reports against HCFs and 1232 were against HMOs. Only two reports were recorded against enrollees by providers,” the NHIA stated.
In addition, 35 HMOs received formal warnings, while 12 were directed to refund N748,200 to 15 enrollees.
The NHIA imposed sanctions, including 84 formal warnings to healthcare facilities, refunds of N4,375,500 to 54 enrollees from 39 facilities, suspension of four facilities and delisting of six others.
According to the NHIA, in 2024, all complaints were fully investigated and responded to within the standard response time of 10 to 25 days.
The organisation said it resolved complaints requiring investigation within an average of 15 days, achieving an 84 per cent resolution rate within the set timeline.
It added that for cases not resolved within the timeline, explanations were provided to complainants while the resolution process continued. Complaints were submitted through various channels, including in person, letters, email, telephone, the NHIA call centre, and others.
“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.
The Director-General of the NHIA, Kelechi Ohiri, stated that the complaints management process aimed to enhance accountability, rebuild trust, and improve the quality of care, driving higher enrollment.
He emphasised that the organisation would not tolerate substandard service, adding that enrollees deserved the best care.
In Nigeria, HMOs provide health insurance coverage for individuals and groups, acting as intermediaries between policyholders and healthcare providers. The NHIA oversees and regulates HMOs to ensure quality healthcare delivery and compliance with standards.
A reporter with the ICIR
A Journalist with a niche for quality and a promoter of good governance