The Health Maintenance Organisation (HMOs) has debunked claim by NHIS boss, Prof. Usman Yusuf, that it owes healthcare providers capitation fees.Publicity Secretary, Health and Managed Care Association of Nigeria (HMCAN), Dr. Lekan Ewenla, made this known in an interview with The Guardian.

He said: “If there’s any outstanding, it’s the fee for service and not capitation that some of the HMOs are owing. Over the years, N351b was paid to HMOs, but 70 per cent of this has been transmitted to hospitals for services provided. If there is any evidence that any HMO owes, that HMO should be sanctioned.

“At quarterly basis, when the HMOs are paying health care providers, the NHIS sends its staff to check if any hospital is not paid. When such happens, the money is immediately refunded back to them.”

Dr. Ewenla said the NHIS boss contravenes the law by going directly to health care providers. “According to the law, the NHIS is not expected to collect premium from any individual apart from the one assigned to them. They are not meant to be fund managers or to market any health insurance product. The NHIS is the regulator of all the schemes, but they never bother to regulate, as they are only interested in collecting one percent of accrued premium by the individual HMOs,” he said.

On the issue of ghost enrollees, Dr. Ewenla said NHIS should also be blamed for such things, since they are the one in charge of giving out the forms. “The NHIS should look into the forms very well before uploading, so as to discover such errors. In the past, a few HMOs were found culpable of colluding with some FCT staff to have some fake enrollees, but this was detected and the culprit dealt with,” he said.Reacting to threat by NHIS boss not to re-accredit HMOs, Dr. Ewenla said it’s NHIS Governing Council that has the power to re-accredit HMOs, and not the Executive Secretary.

He accused the NHIS boss of instigating health care providers against HMOs, in an attempt to discredit them and bring in his northern counterparts.He, therefore, called on the Presidency, the National Assembly and the Judiciary to set up a high-powered investigative committee to probe NHIS’ functions since inception, redirect or re-emphasise its statutory functions and possibly begin to consider the creation of a separate entity, which would anchor the disbursement of funds. 

Ewenla suggested that NHIS should account for all the money it has deducted from contributions, as well as change the body to National Health Commission to make it strictly a regulator.

Meanwhile, the president, Health Care Providers Association of Nigeria (HCPAN) Abuja Chapter, Dr. Festus Odia, told The Guardian that most HMOs owe more of fee for service, and not capitation. He, however, complained that the value of the capitation is not commensurate with services being rendered.

“The capitation does not make sense again, considering the inflation in the country. For instance, the cost of PCV is still N150, while some surgery is N10 under the scheme. Even if you want to operate a mosquito, that money will not cover the bill. NHIS does not pay for ambulance and other emergency services. This is the reason why some health care providers tell enrollees that there is no bed.

“The truth is that if there’s corruption in the scheme, NHIS is allowing it. The cost for incubator under the scheme is N14, so you won’t blame any provider that refuses to allow an enrollee use the incubator. Do you know how much they sell incubators and how much it costs to buy fuel these days? The banks are not giving providers money, so where is the quality service going to come from,” Dr. Odia queried.

He said antenatal care and delivery is free for pregnant women, but the Caesarian section is N55. “Even with this amount, patients would still want a consultant gynaecologist and anaesthetic. So that money will not be enough for such service. This is even excluding money for blood and drugs,” he explained.

Also, the National President of HCPAN, Dr. Umar Sanda, has said the capitation fee is now becoming a post payment, instead of the established prepayment method. According to him, this is affecting the quality of service rendered to enrollees.

“Since January, the capitation fee from HMOs has been coming late. Recently, we have been receiving it monthly and irregularly. The HMOs say NHIS is not paying and that the amount being paid is too small. The private hospitals are the ones being cheated, because public hospitals get their normal subvention from government, as well as the capitation,” he said.

Another major problem, according to him, is poor referral of clients to primary health care facilities, and that teaching hospitals have no business doing primary care services such as malaria.

Dr. Sands, who is also the Medical Director of Ajike Sanda Memorial Hospital, Lagos, said majority of enrollees in his facility are Federal Government staff, and that there is need to increase the number of enrollees to include more of the informal sectors.