NHIA orders HMOs to approve treatment within one hour

The National Health Insurance Authority has implemented a new directive aimed at reducing delays in accessing healthcare services and enhancing patient care.

It said the authorisation of care and issuance of authorisation codes by Health Management Organisations shall no longer exceed one hour from the time of requests by providers and healthcare facilities are to promptly submit requests for authorisation codes to HMOs to mitigate service access delays to enrollees.

The National Health Insurance Act of 2022, signed into law on May 19, 2021, replaced the 1999 National Health Insurance Scheme Act. Its primary aim is to regulate and integrate health insurance schemes, ensuring that every Nigerian has mandatory health coverage while catering to vulnerable groups.

In addition to the one-hour limit, the NHIA outlined several steps to ensure better service delivery, including improved communication from HMOs when authorisation is not possible within the stipulated timeframe and provisions for emergencies where authorisation codes are not required before treatment.

It noted that in fulfillment of its regulatory role to promote patient health outcomes by improving efficiency and access to care, it has directed all its stakeholders on steps aimed at

reducing delays in accessing services and ensuring that enrollees receive quality healthcare services.

“This has become imperative in view of notable delays in authorisation of treatment and issuance of codes, which continues to negatively impact beneficiaries’ experience. These steps consistent with the effective implementation of the NHIA Act 2022, the following changes regarding authorisation of care were approved at a Stakeholders’ Meeting in February help address delays.

“These include: Authorisation of care and issuance of authorisation codes by HMOs shall no longer exceed one hour from the time of requests by providers. Healthcare facilities are to promptly submit requests for authorisation codes to HMOs to mitigate service access delays to enrollees. Communication of a response of ‘no authorisation within the one-hour period where the HMO has justifiable reasons for not issuing the requested code.

“Maintenance of records of all requests and responses for treatment authorisation by providers and HMOs. Where delays occur, beyond the one-hour timeline, the healthcare providers are to proceed to render services to the enrollee and inform NHIA immediately. The NHIA will verify that such services were rendered.”

It urged enrollees are to report any delays or barriers to timely access to health service resulting from receiving authorisation codes in excess of the one-hour limit independently to the NHIA.

“For all emergencies cases, authorisation codes shall not be required before commencing treatment but shall be obtained with 48 hours of commencing care as stipulated in the operational guidelines.

“Sanctions shall be applied appropriately to entities deliberately delaying authorisation of care.

“The NHIA will regularly review compliance with this revised timeline and provide feedback to stakeholders,” it added.

Recently, the Coordinating Minister of Health and Social Welfare, Prof Muhammad Pate said President Bola Tinubu’s administration is taking significant steps to strengthen Nigeria’s healthcare system by increasing financial support for healthcare providers, approving a more than 90 per cent increase in capitation fees and a 378 per cent rise in fee-for-service payments.

Prof Pate stated that adjustment is aimed at easing the financial burden on healthcare providers nationwide, ensuring they have the necessary resources and tools to deliver the highest quality of care to Nigerians enrolled in the national health insurance scheme.

As of December 2024, no fewer than 19.2 million Nigerians have enrolled on the health insurance schemes surpassing its 2024 target.

https://www.msn.com/en-xl/africa/nigeria/nhia-orders-hmos-to-approve-treatment-within-one-hour/ar-AA1Cr5RH