Without digitally confirming a patient’s health insurance information, HMOs and hospitals are often unable to quickly verify if a patient is covered by a health insurance plan, SODIQ OJUROUNGBE writes.
It was a hot, humid day in Lagos when a technologist at the Yaba College of Technology, Simon Jejelowo, felt a wave of panic run through his body as he approached the hospital recommended by his HMO, Princeton Health Limited.
He had been experiencing ear pain for several hours and knew that he needed urgent medical attention.
But as he entered the hospital, he was literally confronted with a wall of bureaucracy.
Jejelowo was informed by the receptionist that he would have to wait for a while as his HMO would have to be contacted to confirm and verify his insurance coverage.
The young man’s heart sank as he realised that he might have to wait for hours before receiving any medical care going by his previous experiences.
As the hours ticked by and the pain in his ear increased, Jejelowo made frantic efforts to reach his HMO but the phone lines were busy. At one point, he was overwhelmed by a deep sense of despair and hopelessness and he tried hard to fight back tears.
Narrating his ordeal to PUNCH Healthwise, Jejelowo said he was told by the nurse that the hospital was unable to reach his HMO and without verifying his insurance coverage status, the facility will not provide him with any treatment.
Feeling trapped in a never-ending cycle of waiting and uncertainty, and determined to end the traumatising pain which was gradually spreading in his head, the technologist had to pay out of pocket for treatment.
“The hospital was bent on getting a confirmation before commencing treatment but my HMO refused to respond. I spent over N100,000 on treatment. The insurance company has not been living up to its responsibility,” he lamented.
For many Nigerians, Jejelowo’s story is all too familiar and has become a norm. Daily, they are faced with a system that is slow, inefficient, and frustrating, and which makes access to healthcare difficult, especially during emergencies.
Findings by PUNCH Healthwise showed that the lack of a digitalised system for managing health insurance is a major factor responsible for this type of bottleneck.
It was gathered that without being able to quickly and easily confirm insurance coverage, patients are often forced to wait endlessly to receive needed healthcare.
Over ten health insurance enrollees told our correspondent that waiting for confirmation through phone calls and messages has denied them access to medical care despite being referred by their HMOs to preferred hospitals.
How health insurance operates
The NHIS was established by the Federal Government of Nigeria under Act 35 of 1999, but was launched in 2005, to “Protect families from the financial hardship of huge medical bills; limit the rise in the cost of health care services; to ensure equitable distribution of health care costs among different income groups, and to maintain high standards of health care delivery services within the scheme.”
In 2022, former President, Major General Muhammadu Buhari (retd.), signed into law, the National Health Insurance Authority Bill 2022.
The bill repealed the National Health Insurance Scheme Act of 1999 and established the National Health Insurance Authority Act, of 2022, to oversee and regulate Health Insurance Schemes.
According to the summary of the new Act, the NHIA was given new and enlarged duties that enable it to operate as a regulator, implementer, investor, and insurer of health insurance policies and programmes in Nigeria.
With the establishment of the NHIA Act, every Nigerian is mandated to get health insurance coverage.
Also under this Act, employers are expected to pay 3.25 per cent, while employees pay 1.75 per cent of the fund, which represents five per cent of their consolidated salary.
Insurance firms called HMOs are licensed by the NHIA to oversee the delivery of quality healthcare services using various health institutions.
An employer, who is satisfied with a health plan meant to be provided for its employees by a particular HMO, pays once an agreement has been reached.
Once a health insurance enrollee has paid the premium, which is a sum for the predetermined healthcare services, the HMO will then pay the capitation (money deducted from the beneficiaries’ salaries) to accredited healthcare providers, such as hospitals and clinics, on behalf of the enrollees.
After this has been done, the employees can access the health services covered by the plan.
PUNCH Healthwise, however, gathered that for any NHIA enrollee to benefit from the insurance coverage at any point in time, a reference number must be obtained from the HMO, which stands as an authorisation for treatment to commence at the preferred hospital.
It was discovered that the hospital would also have to contact the HMO to verify the validity of the reference number and if the patient’s desired treatments are covered by the health insurance plan.
Our correspondent gathered that the hospitals usually encounter delays in getting the needed confirmation.
An NHIA staff at the Lagos University Teaching Hospital, Idi-Araba, who pleaded anonymity said the confirmation is to ascertain whether the insurance plan can cover the patient’s treatment.
While stressing that the hospital may not attend to the patient until confirmation is received, the source added that calling is also meant to ensure that the person brought to the hospital is eligible for health insurance.
“There are times that people will bring a patient that is not covered by their health insurance plan to the hospital for treatment. So, we need to call the HMO to confirm.
“There are several instances that HMOs don’t pick up when we call to get confirmation, which is challenging for us. If we have digitalised data where we can just input a patient’s referral number and see every information that would be a great improvement to the system.
“Having to call when there is an emergency is also risky, but if the data is digitalised, I feel it is going to help the process and make us have a better service.”
Using digital identity
Experts have argued that digital identity could revolutionise health insurance in Nigeria by providing a secure, reliable way to verify and authenticate individuals.
They lamented that the lack of verified patient identities leads to increased costs, delays in treatment, and potential errors in care.
While stressing that manual verification is time-consuming and prone to error, leading to delays in payment and claims processing, the experts said using digital identity to streamline and automate the health insurance process is the best way to tackle the challenges.
According to them, without a reliable way to verify insurance coverage providers may be more likely to provide substandard care or even deny care to patients who are unable to prove their coverage.
A doctor at a hospital in Lagos, Dr Funke Obembe said that the current system is a huge challenge for both patients and doctors, adding that it takes up valuable time that could be spent on more important things, like providing care.”
She noted that a digitalised system where information of enrollees can be accessed would hold several benefits for both patients and healthcare providers.
“We have seen instances where patients were denied care because they couldn’t provide the necessary documentation. This is a grave injustice and one that could be avoided with a digitalised system.
“We need to take this step to create a system that is truly for the people and by the people,” Obembe added.
A digital expert, Igbagboyemi Oladele explained that digital identity could solve many of the challenges currently plaguing the health insurance system in Nigeria.
“By creating a system that verifies the identity of patients and streamlines the process of sharing medical records, we can make it easier and faster for people to get the care they need,” he added.
Oladele noted that digital identity could also help to reduce fraud and corruption within the health insurance system.
He explained that digital identity could provide a higher level of security and transparency, making it harder for criminals to take advantage of the system.
“We must modernise our approach to health insurance. By using digital identity to simplify and automate the process, we can make it more effective and accessible to all Nigerians.
“Digital identity is a critical piece of the puzzle when it comes to reforming the health insurance system in Nigeria. It can provide a secure and reliable way to verify the identity of individuals, making it more difficult for criminals to defraud the system. And by increasing transparency and accountability, we can create a more trustworthy and effective system for all,” the digital expert said.
“This report is produced under the DPI Africa Journalism Fellowship Programme of the Media Foundation for West Africa and Co-Develop.”
