HOSPITALMGT NIGERIA

2011

NHIS: all you needto knowA practical guide for healthcare providers

ohi ohioze

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COPYRIGHT NOTICE

NHIS: all you need to know

By OHI OHIOZE

Copyright© 2011 by Hospitalmgt Nigeria

Published by Hospitalmgt Nigeria

You have my express permission to post, email, and print or distribute for FREEthis eBook as long as you make no changes or edit its contents. In fact I encourageyou to distribute several copies to as many medical and dental practitioners thatyou know. The NHIS is central to the development of the health sector. Everyoneshould participate in the Scheme to make it successful.

All other rights are strictly reserved.

DEDICATION

This book is dedicated to the three girls in my life; Nyero, Ruby and Tara. Youmake life worth living.

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INTRODUCTION

There are several perspectives in understanding the National Health InsuranceScheme. It can be viewed from the regulatory perspective, or from theperspective of a beneficiary. However, I will write this book from the perspectiveof a Healthcare Provider.

The National Health Insurance Scheme (NHIS) is a Social Health Insurance Schemewhich was established in Nigeria to subsidize the healthcare costs of Nigerians.

As in all Health Insurance Schemes, the healthy are expected to pay for thetreatment of the sick. This is done through the pooling together of monthlycontributions from the Country’s citizens. A percentage of this amount is paid tothe hospitals on a monthly basis. This ensures that funds are always available inthe registered hospitals to pay for the treatment of the sick.

In my interaction with Medical Doctors, I discovered that a lot of them do notunderstand how the Scheme works. Though, Doctors know that they areStakeholders in the Scheme, most do not fully understand their role in theScheme. Worse still is the fact that a good number of Private Hospitals haverefused to tap into this veritable source of income. This may be because theybarely understand the scheme or they are reluctant to try something new. I willlike to explain to you the basics of the NHIS and how you can participate fully as aHealthcare Provider. The Scheme is awash with funds presently and you have alot to gain by aligning yourself with the NHIS.

Presently, the Public Hospitals have the greatest number of enrollees. This shouldnot be because most Public Hospitals are meant to be Secondary or TertiaryProviders.

Nigeria has a huge population (approx.167 million people) that can sustain theScheme for years to come. With only 5 million enrollees (approx. 3%) presently,you can imagine the untapped potential of the NHIS. You should not be leftbehind. Before we proceed, let us understand the concept of managedhealthcare.

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Concept of Managed Healthcare

Managed healthcare is the integration of the financing and delivery of healthcareservices within a system that seeks to manage the accessibility, cost and quality ofthat care. As a healthcare provider, you must have at one time or the otherencountered situations in which you found it difficult to get patients or you arefaced with clients who need healthcare but cannot pay or are reluctant to payafter receiving treatment. Your staff may be going from office to office begging tobe paid for services that you have rendered. Conversely, you may be unable to payyour staff salaries at month end or you find it difficult to obtain specialist care foryour patients.

Under the managed healthcare system, a third party called a Health MaintenanceOrganization (HMO) elects to seek out interested individuals and Organizations,collects payments from them for healthcare services and contracts withhealthcare providers to provide accessible, cost effective and quality healthcareservices to their employees and /or dependents. (International HealthManagement Services LTD Provider Service Manual pp.3).

What this simply means is that the HMO contracts with NHIS registered Hospitalswho provide healthcare to patients. When the hospitals provide healthcare topatients, they pass the cost over to the HMO. The HMO pays the hospitals withthe funds it pooled together from the contributions of the patients. The qualityand cost of this healthcare is regulated by the HMO to ensure uniformity acrossboard.

With the concept of managed healthcare fully entrenched in your mind, let meshow you how you can be a part of the NHIS.

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TABLE OF CONTENTS

INTRODUCTION…………………………………………………………………………………3

HISTORICAL PERSPECTIVE………………………………………………………………….6

DEFINITION OF TERMS………………………………………………..…………………….8

PROGRAMMES AND STAKEHOLDERS……………………………………………….10

HOW YOU CAN BECOME A HCP……………………………………………………….13

HOW THE NHIS WORKS……………………………………………………………………18

HOW DO I GET PAID?.......................................................................25

ATTRACTING ENROLLEES…………………………………………………………………28

ZONAL OFFICES……………………………………………………………………………….33

CONCLUSION…………………………………………………………………………………..35

REFERENCES…………………………………………………………………………………….36

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CHAPTER 1

HISTORICAL PERSPECTIVE

The idea of a Social Health Insurance Scheme in Nigeria was first conceived in1962 by the Halevi Committee. The Committee was set up by the then FederalMinister of Health, Dr. M. A. Majekodumi. The proposal was passed through theLagos Health Bill in 1962 but was defeated.

The idea was again resuscitated in 1984 by the then Minister of Health, AdmiralPatrick Koshoni. In 1985, another Minister of Health Dr. Emmanuel Nsan set up aCommittee which reported that Health Insurance is viable in Nigeria.

Prof. Olikoye Ransome Kuti subsequently raised a consultative Committee on theNHIS in 1988 which recommended an acceptable model for the implementationof the Social Health Insurance in Nigeria. The Federal Government of Nigeria thenapproved the establishment of the Scheme in 1989.

Health Maintenance Organizations (HMOs) were introduced as FinancialManagers of the Scheme at the 42nd meeting of the National Council of Health.

After over 37years since the idea was first conceived, the NHIS was launched onOctober 15th, 1999. The enabling Law backing the Scheme is Decree 35 of 1999(now Act 35 of 1999) signed in May 1999.(see www.nhis.gov.ng)

It took another 6years before commencement of services to enrollees started inSeptember 14, 2005. (Formally launched on June 6th, 2005)

Presently, the Scheme has over 5million enrollees. There are 61 accreditedHMOs, 7,850 Healthcare Providers, 24 Banks, 5 Insurance Companies and 3Insurance Brokers participating in the Scheme.

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The Federal Government is the major participant in the Scheme. Only 2 out of the36 States in Nigeria have fully rolled into the Scheme. These States are Bauchi andCross River. About 22 other States are warmly up to enroll their workers in theScheme. The Organized Private Sector (OPS) has also enrolled in the Scheme.

If you divide 167million Nigerians, (recent population statistics from NPC) by the(approx.) 8000 Healthcare providers, you will get 20, 875 enrollees per Facility.Can one facility realistically cater for 20, 875 patients? The answer is no. That isthe reason why you must tap into this “goldmine” of a Scheme now.

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CHAPTER 2

DEFINITION OF TERMS

Let’s define some terms that you will encounter in the NHIS.

1. Enrollee: This is an individual who is registered under the Scheme to accesshealthcare. He may be an employee or a dependant of an employee

2. Capitation: Capitation is a fixed amount payable per enrollee per monthirrespective of number of visits or services received within that month.Presently, capitation is N550 per enrollee per month (for public sector) andbetween N500-N1000 per enrollee per month (for private sector).Capitation is usually paid in advance. The number of enrollees you havedetermines the number of capitation you receive. A family consisting offather, mother and two children equals four enrollees. So ten of suchfamilies equal forty enrollees. Each family is allowed to register only sixenrollees. Any additional enrollee is registered separately by the Principal.The Principal is the person who actually pays for the other enrollees. ThePrincipal may be the father or the mother of the family. Capitation is meantto cover primary healthcare.

3. Fee for services: This is the amount that is paid to you for services youprovide beyond primary care. It could be surgeries, laboratory services,physiotherapy e.t.c. however, before you provide such services toenrollees, and you must be registered by NHIS to provide secondary care.You must also get authorization from the HMO in charge of such anenrollee. Failure to do this will result in non-payment of your claims. Fee forservice payment is based on NHIS tariffs. That means that the NHIS hasfixed amounts to be paid for any secondary care you provide. Only withexpress permission from the HMO can you charge above this tariff.

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4. Health Maintenance Organization (HMO): This is a private or publicOrganization which has been registered by the scheme to act as anintermediary between the enrollee and the health care provider. HMOs aremostly private Organizations. They collect contributions from employeesand employers. They use some of these contributions to run their affairs,remit some to the NHIS and pay some to the primary care providers ascapitations. They also pay for any secondary care provided through the fee-for-service. HMOs enter into contractual agreement with the health careproviders accredited by NHIS before they can pay capitation.

5. Health care provider (HCP): The healthcare provider is you, the Hospital.HCP means any government or private healthcare facility approved andregistered by the scheme to provide healthcare services to enrollees.

6. Encounter Data: This is the information indicating the enrollee visits to theHCP. You must send monthly reports to the HMO specifying the name ofpatient, patient’s NHIS number, diagnosis, treatment and admission days (ifadmitted).

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CHAPTER 3PROGRAMMES AND STAKEHOLDERS

The aim of the National Health Insurance Scheme is the provision of easyaccess to healthcare for all Nigerians at an affordable cost through variousprepayment systems. This is being achieved through the development ofvarious programs to cover different segments of the society.These are:1. Formal Sector Social Health Insurance Programme:

Under the formal sector programme, there are

(i)Public sector (federal, state and local government)This was the first to kick-off. It involves mainly Federal Governmentworkers for now. As stated earlier, a lot of states have begun to log intothe Scheme. When the Scheme is fully operational, it is expected that allthe 36 States including the FCT will be participants.(ii)Armed forces, police and other uniformed services(iii)Organized private sector

These are already part of the scheme. As well as (ii) above.(iv)Students of tertiary institutions and voluntary participants.They are currently being enrolled into the NHIS.

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2. Informal Sector Social Health Insurance Programme

Under this programme, there are

(i)Rural Community Social Health Insurance Programme

(ii)Urban Self Employed Social Health Insurance Programme

3. Vulnerable Group

(i) Children Under –Five Social health Insurance Programme(ii) Permanently Disabled Persons Social Health Insurance Programme(iii)Pregnant women and orphans Social Health Insurance Programme

4. Others(i) Recently, the NYSC Social Health Insurance Programme was launched(ii)International travel health insurance.(iii)Retirees and unemployed

NHIS StakeholdersThe following are stakeholders in the National Health Insurance Scheme:1. Government

The government sets standards and guidelines which protects the rightsand enforces the obligations of all stakeholders.

2. EmployeesThese, together with their dependants are the enrollees (or patients).They contribute 5% of their basic salary to the Scheme.

3. EmployersEmployers contribute 10% of the basic salary of their employees into theScheme. They are Public or Private Sector Organizations employingmore than 10 persons.

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4. Health Maintenance OrganizationsThey perform 3 functions:(a) Receive contributions from employees, employers and voluntary

contributors(b) Payment of healthcare providers for services rendered(c) Maintenance of quality assurance in healthcare delivery services.

5. Healthcare ProvidersThese are licensed Public or Private Healthcare Facilities which havebeen registered by the Scheme. They can either be primary, secondaryor tertiary healthcare providers.

6. Voluntary ContributorsThese are people who are basically self-employed. They include theUrban Self-Employed and Rural Community dwellers.

7. Board of TrusteesThey plan, run and manage the healthcare needs of the voluntarycontributors.

8. Other StakeholdersThey include: Banks Insurance Companies Professional bodies Insurance Brokers Community Leaders The Media Non Governmental organizations International Organization

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CHAPTER 4HOW YOU CAN BECOME A HCP

We have defined the term HCP or Health Care Provider. There aredifferent categories of Providers:Primary, Secondary or Tertiary1. Primary Healthcare Providers:

They serve as the first contact within the healthcare system. Theyinclude: Private Clinics Primary healthcare centers Nursing and maternity homes OPDs of General Hospitals, FMCs, Teaching Hospitals and Staff

Clinics

2. Secondary HCPs (Fee-for- service Providers):

These are HCPs registered for Secondary care. They include:

Private Hospitals that have registered their Pharmacy, Surgery,Obstetrics and Gynecology etc.

General Hospitals Specialist Hospitals Dental clinics Pharmacies Laboratories Physiotherapy

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Radiotherapy etc.

3. Tertiary HCPs:

These are also fee- for –service providers. They are basically theTeaching Hospitals.

Having understood the different categories of healthcare providers, Iadvise you register as both a primary and a secondary provider. You willget maximal benefits from the Scheme that way.

Let me show you how you can become a HCP in 10 Simple Steps.

Step 1: Go to the NHIS Zonal Office closest to you. (I will give you theiraddresses later)

Step 2: Pick your registration form(s). It cost N5000 to purchase aregistration form from the NHIS office. After filling the form you will payN10, 000 to be accredited as a Primary HCP. For the secondaryproviders, you are expected to pay an additional N10, 000 per specialtyyou wish to register i.e. to register your Pharmacy, laboratory, Surgery,Pediatrics etc.; you pick a form and pay N10, 000 for each Specialty.

NB: I advise you register your Laboratory and Pharmacy even if you are aPrimary HCP. This will ensure that your patients do not have to gooutside your facility to access these services.

Step 3: Fill the form(s) appropriately and return it/ them to the NHISoffice.

Step 4: Ensure you meet all their requirements (more on this later)

Step 5: NHIS and HMO Officials will inspect your Facility

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Step 6: if you meet their requirements, you will be issued a RegistrationCertificate(s) and NHIS poster. You are to conspicuously display thePoster in your Facility.

Step 7: Sign contractual agreements with HMOs. You can sign with asmany HMOs that approach you. There is no limit to the number ofHMOs that you can relate with.

NB: You need to sign with as many HMOs as possible because each HMOhas a specific segment of the society that it covers. For example, a HMOmay cover workers from the Federal Ministry of Transport only; anothermay handle the Police Force and Immigration Services. So the moreHMOs you sign with, the greater the potential number of enrollees youwill get.

Step 8: After signing the necessary documents, you will receive yourenrollee list along with your capitation payment. (Capitation is paiddirectly into your bank account or through bank cheques sent to youquarterly).

Step 9: Open a separate folder for each enrollee sent to your Facility.

Step 10: Start attending to the enrollees as they come.

NB: Ensure you keep good records of your interactions/payment detailswith each HMO. You should have separate official files for each HMOwhere you keep their letters and other correspondences between you.

NB2: Assign an administrative staff to manage this information. As theyears go by, your files will become quite bulky and difficult for you tomanage alone.

The registration process may take between 2-3months. So, commence ittoday!

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Private Hospitals Registration Guidelines

Depending on your status- either primary or secondary, the followingguidelines are applicable (NHIS Guidelines on Registration 2000):

(a)Primary Medical Center:

Out- patient Facilities should have the following minimum features:

Waiting and reception area measuring at least 4x3metres (the sizeof an average sitting room) which should contain sitting facilities,reception and registration table and medical records keepingFacilities.

Consulting room measuring 4x3metres with examination couch,equipment for complete physical examination, running water andhand towels.

Treatment room also measuring 4x3metres with instrumentscabinet, dressing and injection trolley and equipment, runningwater and hand towels.

Adequately stocked and maintained Dangerous drug Act (DDA)Cupboard.

Patients toilet Facilities Drug dispensing room Sterilizer

(b)Secondary Medical Center: In addition to the above, you need Specialist Facilities specific for

each of the Specialty registered. A toilet for every 12 beds A bathroom for every 8 beds Nurses’ bay Doctor’s room

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Personnel Requirements(a)For the Primary Provider, you are expected to have:

At least one medical doctor At least two registered nurses At least two hospital assistants At least one administrative staff At least one dispensary staff (with Pharmacist supervision)

(b)For the Secondary Provider, you should have: At least one registered specialist in the relevant specialties

accredited At least four registered nurses and midwives At least four Hospital assistants At least 2 administrative staff

In addition to the above, each professional must show evidence ofregistration with their Professional Association. All staff shouldalso be covered with a malpractice Insurance. You can get thisInsurance Policy from NICON Insurance or IGI Insurance Company.

You also need a Malpractice Insurance Policy to cover yourfacility. This will not cost much. You can actually take a policy ofN1.5 million which is the minimum required. You will then pay apremium of N15, 000 per annum for as long as the policy lasts.

As a Primary HCP, you are expected to

Provide quality healthcare to enrollees in a conduciveenvironment

Provide education to enrollees and the community about theScheme

Gather information on the Scheme and send this informationmonthly to NHIS and HMOs.

Now, let’s see how the Scheme works.

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CHAPTER 5

HOW THE NHIS WORKSAfter accreditation the NHIS will provide you with two veryimportant documents-the NHIS Essential Drug List and the NHISFee-For-Professional-Service Tariff. The Drug List is the same asthe National Essential Drug List but in addition, it contains fixedprices for each drug. This is meant to guide you when calculatingthe cost of drugs you prescribe. The Fee-for-service Tariff containsa list of all the procedures approved by the Scheme along withtheir pre-determined prices. These procedures include surgeries,radiological investigations, laboratory investigations,physiotherapy sessions e.t.c.Most of the HMOs will also send you their guidelines, drug listsand professional tariffs. These are essentially derivatives of theNHIS documents. There are a few differences especially for theOrganized Private Sector Schemes.

Now that your hospital has been accredited, how do you goabout attending to the enrollees?First, you will receive an enrollee list with the enrollee photopanel from all the HMOs you have signed agreement with. Eachphoto panel will contain the photographs and names of aparticular family. You are advised to open an individual folder foreach enrollee and attach the photo panel to the inside-front coverof the folder.I will also advise that you create a register/database containingthe names of all your enrollees regardless of HMO. Mostenrollees do not know what HMO means and who their HMO is.

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So trying to identify them by HMO may be difficult. Compile thedatabase/comprehensive register of the enrollees as the namesare sent to you from their different HMOs.Next, when an enrollee comes for healthcare, you should identifythe enrollee. Note that you must not allow an enrollee to bring hisfriend, or mother, or uncle who is not registered. Givingtreatment to such a patient under the Scheme will defeat thepurpose of the Scheme and reduce your profit margin. However,as a healthcare provider you should encourage such a patient tohave his/her own separate folder and pay out of his/her pocketfor the treatment given.You can identify enrollees through:(a)Identity card: Each HMO issues ID cards to their enrollees.(b)Enrollee name and photo panel: Match the face of the patientwith the image on the photo panel.(c)NHIS Enrollee list: In the event that (a) and (b) are not available,you should confirm if the enrollee’s name is in the NHIS list.(d)Call HMO: Finally, you can call the HMO to confirm enrolleeeligibility.

NB: For registered patients (with HMO ID Cards) who present inemergency but whose names are not on your list, you can renderimmediate resuscitative services and notify their HMO within24hours.The HMO will give you a treatment authorization code.The HMO will usually pay you on a fee-for-service basis for suchpatients when you present the bill and the authorization code.

After identifying enrollee and confirming eligibility, the patientshould fill the attendance form. After this, you render theappropriate service to the enrollee.

NB: However, there are some exclusions to the type of servicesyou can provide. These exclusions are occupational/industrial

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injuries, terminal illness including all cancers, overseas treatment,infertility treatment, cosmetic surgery etc.

After attending to the enrollee, please fill the NHIS prescriptionform. The enrollee then takes the prescription to your pharmacy(if it is accredited) where the cost of the drugs are calculatedaccording to NHIS Drug List. The patient then pays 10% of thecost of the drugs and is given his/her drugs.E.g. if your prescription is:Tabs Ciprofloxacin 500g b.d x 1/52Tabs Diclofenac 50mg b.d x 5/7According to the NHIS Essential Drug List:Ciprofloxacin cost N65/tablet; N65 x 14 = N910.Diclofenac cost N20/tablet; N20 x 10=N200.The Total bill is N1, 110

The patient is expected to pay 10% which is N111.The remaining 90% is covered by capitation.

ReferralsUnder the Scheme, when a patient requires secondary care e.g.appendectomy, he/she should be referred to a secondaryprovider (if you are not registered for such care).

The referral process is as follows: Ascertain the provisional diagnosis and the need for a

referral. Decide/determine the secondary provider you are referring

the enrollee to. It should be the closest secondary providerto your facility.

Call the enrollees HMO Hotline/Emergency line to get anauthorization code.

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Fill the referral form provided by the HMO or NHIS. Ensureyou clearly write the authorization code at the top of theform.

Give the referral form to the enrollee and send him/her tothe secondary provider as soon as possible

NB: Do not hold on to patients you cannot manage in your facility.You are asking for trouble if you do. Refer such patients promptly.NB2: Always attach all investigations done at your facility to thereferral form. HMOs do not like paying for the same investigationtwice.

If you are accredited for secondary care, you are expected to alsofollow the steps above. The only difference is that you arereferring the enrollee to yourself. You will need to carry out theabove referral steps so that your claims can be paid.At the end of the month in which you provided the secondarycare to the enrollee, you are expected to calculate your fee-for –service (based on the NHIS guidelines) and send your claims formto the HMO. It is always better to send your claims before the 10th

day of the next month.NB 1: Please note that the patient is still expected to pay 10%(only) of the cost of the drugs used during the procedure. Theremaining 90% is calculated along with the cost of procedure andpaid as fee-for-service by the HMO.NB 2: Also note that any secondary care provided withoutauthorization from the HMO will not be paid. Any bill computedwithout following the NHIS or HMO guidelines will also not bepaid.NB 3: If the case is an emergency, you are expected to go aheadwith the procedure and notify the HMO within 24 hours. TheHMO hotlines are open 24 hours of the day and 7 days of theweek.

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Let’s take an example to explain the referral process.

Mrs. Johnson is a booked G3P2+0 with a transverse lie at term.You have previously counseled her for an Elective C/S which sheconsented to. You are a secondary provider in Obstetrics &Gynecology.Step 1: Call her HMO e.g. Goodhealth HMO Ltd and notify them ofthe surgery. Furnish them with her details; name, NHIS IDnumber, bio data, reason for surgery etc.Step 2: The HMO gives you an authorization code e.g. HMO097/301212/AX 0032/SStep 3: Fill the referral form accordinglyStep 4: Fill the consent form and carry out the surgery. Ensuremother and child are fine.Step 5: After discharge, you calculate the fee for service asfollows:Antenatal Care N5, 000Ultrasound Scan N1, 000Specialist Initial Consultation N1, 000Specialist Review (3 days) N3, 000Nursing Care (4 days) N2, 000Surgery N40, 000Drugs N15, 000Total N67, 000NB: This bill is based on the NHIS Fee for Service Handbook andNHIS Drug Price List (2005).NB2: You are expected to send a list of the drugs used post-op (aswell as the list of discharge drugs)Step 6: Fill the claims form accordingly.Step 7: Send the Medical Report, Referral Form, Claims Form,Consent Form and drug prescriptions to the HMO through CourierService.Step 8: Expect your cheque within 4 weeks.

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Out of Station CareAn enrollee may require urgent care outside his/her usual state ofresidence. This is called Out of Station Care.In such cases, the provider is expected to treat the enrollee afterconfirming his/her eligibility status.You can confirm eligibility status through the Enrollee’s ID cardand by calling the HMO to get an authorization code. At the endof the month, the referral forms (claim form, authorization forme.t.c) are filled and sent to the HMO for settlement of claims.

Relationship with Other StakeholdersAs a provider, you should have a good relationship with otherstakeholders particularly the Enrollees, HMOs and NHIS. (I willdiscuss relationship with Enrollees in another chapter)In relating with the NHIS, you are expected to provide a desk andchair (or an office) in your Facility for the NHIS focal person inyour state. The NHIS focal person is usually sent from the ZonalOffice to monitor the healthcare providers. You are expected tofurnish the focal person with monthly Enrollees’ records,monthly/quarterly capitation payments records and a host ofother records. The focal person may request to go through yourrecords at any time and you are meant to oblige him/her. Thefocal person also handles issues and/or disputes arising betweenenrollees and HCPs or between HMOs and HCPs.Your relationship with the HMOs begins from the point of signingthe bilateral contractual agreement. The HMO has the right toinspect your facility, go through patients ’records and scrutinizeyour bills. You are expected to seek authorization from the HMOsbefore providing/referring enrollees for secondary care. You

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should also call the HMO whenever you require clarification onany issue pertaining to their enrollees. In certain cases, the HMOmay permit you to give drugs outside the NHIS Drug List.To enhance your relationship with other Stakeholders in theScheme, I advise you have a Desk Officer in your Hospital tohandle NHIS matters. This Desk Officer should be anAdministrative Staff whom you will train on the workings of theScheme. The book can be used as a training manual. You can visitthe NHIS website and also attend seminars (organized by theScheme or HMOs) to improve your knowledge of the Scheme.

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CHAPTER 6HOW DO I GET PAID?

I have already explained the payment methods in the Scheme.

Public Sector Payment MethodsThe methods used for payment in the public sector are themonthly capitation payments and the fee for service payment.You should also know that an enrollee is entitled to be admittedinto your facility for not more than 15 days per year. The HMO isexpected to pay for any extra number of days the enrollee spendson admission.Capitation is usually paid quarterly( in advance). Capitation isN550 per enrollee per month. Fee-for-service is paid within 4weeks of submission of claims. (Though most HMOs will insist thatthey will pay your claims within 14 days).

Private Sector Payment MethodsThe capitations paid in the Private Sector Scheme depend on theenrollee medical plan. Capitation may vary between N500 – N1,000 depending on the type of plan the enrollee has. For instance,Hygeia HMO has the Standard plan, Silver Plan and Gold Plan. Inthe private sector scheme, capitation is usually paid to providerswith 51 or more enrollees. For providers with less than 51enrollees, payment is made through the Diagnosis Related Tariff.This is a list of payment amounts related to different diagnosis.egthere is a fee paid for the treatment of uncomplicated malaria.There is another fee paid for treating bronchopneumonia and soon.

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Providers are also paid through Fee-For-Service in the PrivateSector Scheme. Some HMOs actually use this method more thanthe other two methods.

You may wonder how the Scheme can be said to be lucrativewhen capitation is just N550 per enrollee per month. I am goingto show you (through a Hospital’s NHIS records) the profitpotentials of the Scheme. Don’t ask me how I got the records, juststudy them and see for yourself. It is the payment and visitationrecord for a modest HCP with about 500 enrollees.Table of NHIS Records for Hospital X (Jan – Sept, 2007)

Month Total No.ofEnrollees

No ofenrolleesthatvisitedHCP

% ofenrolleesthatvisited(approx.)

Monthlycapitation(N)

AmountSpent(N)

Balance(N)

January 543 36 7 298,650 56,960 241,690February 543 39 7 298,650 55,017 243,633March 548 50 9 301,400 73,900 227,500April 548 44 8 301,400 68,500 232,900May 562 51 9 309,100 75,420 233,680June 562 57 10 309,100 85,110 223,990July 567 52 9 311,850 83,750 228,100August 567 51 9 311,850 89,993 221,857September 560 60 11 308,000 98,557 209,443Total 5,000 440 9% 2,750,000 684,207 2,065,793

From the table above, hospital X had 5,000 registered enrollees innine months. Only 440(9%) of those enrollees assessed care in 9months!! These 440 enrollees also include patients who visitedthe facility more than once in the said period.Out of a total of N2, 750,000 received as capitation in 9 months,Hospital X only spent 25% (i.e. N684, 207). That is hospital X

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made a profit of N2, 065,793(75%) in 9 months. Note that this isjust one of the sources of revenue of Hospital X.NB: Hospital X also had about 900 private enrollees (in the 9months period) not captured in the table above.NB2: Revenue derived from fee-for-service was also not added tothe table.You can therefore appreciate the profit potential of the Scheme. Itis a ready source of hospital revenue. You no longer have to thinkof how to pay staff salaries. Every month, a certain amount ofmoney called capitation is paid into your hospital account. This isirrespective of the fact that the enrollee accessed care or not.However, looking at Hospital X’s table, you will realize that out of9% utilization, the hospital spent 25% of its capitation. This meanshospital X is probably using expensive branded drugs for itsenrollees. This 25% can be reduced by adhering strictly to theNHIS Drug List which favors generic drugs over branded drugs.I am quite sure that the same profit scenario is repeated in somany HCPs.Imagine a HCP with over 10, 000 enrollees!! That is actually thelot of most Public Hospitals. The Private Hospitals shouldtherefore sit up and get their own share of the “NHIS cake”. Thesecret to good profit in the Scheme is the number of enrollees youhave. A Hospital with less than 50 enrollees will probably notmake much profit. I shall discuss how to attract enrollees to yourfacility soon.A word of caution is needed here. The profit derived from theScheme is not meant to be spent on personal excesses. Youshould re-invest it into your facility to purchase standardequipment, erect standard buildings, and hire qualified personneletc. This profit must be seen to make a positive difference in yourfacility. With such an amount, you can effectively plan ahead foryour hospital. You can go back and read the chapter on Planningand Control in the book “Hospital Management Made Easy”.

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Chapter 7

ATTRACTING ENROLLEESTo realize the profit potential of the Scheme, you need a largenumber of enrollees. Most Insurance people will tell you that themore customers they have the more profit they make. Think ofyour car insurance policy. It is mandated by law. You pay premiumevery year. So do millions of other vehicle owners in the Country.How many times have you made a claim to your insurancecompany? (Let’s not talk about all the processes you go throughbefore your claim is paid). My guess is that you have never madeany claim. The point is what happens to all that money? The hugeresources in the insurance industry go somewhere. I won’t saywhere.The secret of generating this revenue is the customer base. Getthe customers to come, you get the cash.I will show you several things that you need to do to help youattract (and retain) enrollees to your hospital.

1. HonestyA friend of mine who is an enrollee based in Ibadan changedproviders twice in less than 2 years. Even with the secondprovider, he refused to utilize the facility more than four times.He eventually moved out of Ibadan and changed his HCP to hisnew location. What was his grouse? It was Dishonesty! His firstHCP lied that the NHIS only pays for drugs like chloroquine intreating malaria. He was also told that payment was notregular. He was often billed above the 10% fee he wassupposed to pay. Those two facilities lost 6 enrollees becauseof dishonesty.

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The first advice I will give to you is to be honest. Enrollees areattracted to facilities that are honest and forthright. Nobodylikes being cheated (no matter how small the amount). If theScheme says the bill N950, collect N95 (10%) only from theenrollee. Do not increase it to N150. Enrollees frequentlycompare notes with each other. They will know when they arebeing cheated and they will leave you for honest HCPs.

2. Adhere to NHIS GuidelinesThis is closely related to the point above. Please follow theNHIS guidelines as much as possible. Don’t collect more thanthe stipulated charges. Don’t give substandard drugs.

3. Prompt ServiceThe main reason why patients seek private healthcare is thatthey want to receive prompt attention. Render promptservices. Enrollees do not want to wait on endless queuesbefore they can access healthcare. Try to reduce your patientwaiting time at each point of the hospital process (Get mybook, Understanding Private Practice). When you renderprompt services, enrollees will be attracted to your facility.

4. 24 Hour ServicesIn addition to rendering prompt services, you can go a stepfurther and keep your doors open for 24 hours. NHIS enrolleescan come to your facility at any time. If there is no doctor toattend to them, they will eventually transfer to another facility.We recently lost some enrollees to another HCP because therewas no doctor-on-call the night they came. We have sincecorrected that anomaly. Patients have greater confidence inyour facility when they know that they can access care even at2am.

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5. Friendliness and CourtesyA popular saying goes “He who wants friends must first makehimself friendly”. The hospital staff must be friendly andcourteous at ALL times. Your hospital environment must bewelcoming. The patient should feel at ease when he/she visitsyour facility.From my interaction with NHIS enrollees, I discovered thatthey want to be treated as the “nouveux rich”-the best thing inhealthcare. Therefore your ability to make them feel importantwill give you an edge over others in attracting enrollees.Change your attitude from the harsh, stern faced, no nonsensedoctor to that of a loving, caring and hospitable healthcareprovider. Beware, however of pampering enrollees. It could becounter- productive.

6. Existing PatientsYou will probably have an initial patient base before youregister with the Scheme. You should consciously “preach thegospel” of NHIS to such patients. A lot of State Governmentsare coming onboard; also the urban self-employed SocialHealth Insurance Scheme is about to kick-off. These patientshave been accessing healthcare somewhere before theScheme started. That somewhere may be your facility.Encourage such patients to register with the Scheme andchoose your facility so they can continue their existingrelationship with you. Make them see the benefits ofremaining in your Facility. “Convert” them. Note that if youhave not being good to them in the past, they will probably seethis as an opportunity to run away from you. However, mostpatients will still choose your facility due to customer loyalty.

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7. Hospital “Evangelists”Hospital Evangelists are enrollees that inform other patients(their co-worker, neighbors, friends e.t.c) of the goodies theyenjoy in your Facility. They will definitely boast of thesuperiority of their HCP to their friends. Try to identify suchenrollees and actively encourage them to attract otherenrollees. You can do this simply by giving them qualityservices. You don’t necessarily have to say to them “bring yourfriends”. Your good actions will be louder than your words.

8. QualitySuccess has many parents but failure is an orphan. Give goodquality services and you will attract enrollees. Give poorquality services and you will repel enrollees. Read the chapteron Total Quality Management in my book” HospitalManagement Made Easy”.

9. Specialist ClinicsOne of the major reasons why enrollees prefer public hospitalsover private hospitals is because of the somewhat erroneousbelief that they will get access to consultants in the publichospitals. This belief is only partly true. First, most enrollees donot need specialist care at all and can be treated at theprimary level (private hospitals). Secondly, Consultants aredefinitely not the first doctors to see patients in publichospitals. This is usually left for other junior doctors. Thirdly, aconsultant will give a patient more time and attention in aprivate facility than in a public facility where he has a long lineof patients waiting to see him.

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Healthcare workers know this but most enrollees don’t. Sowhile you are still trying to educate enrollees, offer themprompt specialist services when needed. However, you needto have been accredited by the NHIS for such specialistservices. The key therefore is to get your hospital accreditedfor specialist (secondary) care and to inform enrollees aboutyour status as a secondary provider. This will boost theirconfidence in your facility and attract other enrollees. Makesure that you actually get a specialist to render secondary care.

10.Discipline and PersistenceIn the final analysis, you need discipline and persistence tosucceed in any business venture. Attracting enrollees takestime and you have to keep at it. Apart from public hospitalsthat do little or nothing to attract (and retain) enrollees, everyprivate hospital on the Scheme has to keep on working. Don’tquit. Winners don’t quit and quitters never win.

Enrollees may leave your facility for several reasons e.g. thosewho attain the age of 18, those who transfer out of town, andthose who may have lost confidence in your facility etc. Butyou must ensure that for every single enrollee that leaves, youattract 10 more.Use the information contained in this book. I assure you that ifyou do, you will be smiling to the bank in a few short years.

NB: To learn more on hospital management, get my book“HOSPITAL MANAGEMENT MADE EASY”. Visitwww.hospitalmgt.com.

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Chapter 8ZONAL OFFICES

It will be a waste of time if you have gone through this bookand yet do nothing. Any information received that is not put touse becomes useless. Procrastination is a potent killer ofvision. So I am going to give you the contact addresses of theNHIS Headquarters and Zonal Offices. I want you to get yourhospital registered today!! The journey of a thousand milesactually begins with one simple step.The NHIS has offices in all six geopolitical zones of Nigeria. Inaddition, the headquarters is in Abuja. States that have fullyrolled into the Scheme has NHIS Offices. Such States areBauchi and Cross River. All other states have an NHIS focalPerson or Desk Officer. These Officers have been sent from theZonal Offices to ensure the smooth running of the Scheme.Usually, every registered HCP should provide officeaccommodation for the desk officer. The Desk Officers spendtheir time amongst the different HCPs on a daily or weeklybasis. To contact them, go to any of the HCPs in your area andask for the NHIS Desk Officer. However, because of the largeenrollee population in Government Hospitals, they spend mostof their time there. You are most likely to meet them in PublicHospitals.

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ADDRESSESHeadquarters OfficeThe Headquarters of the National Health Insurance Scheme islocated at Plot No. 297, P.O.W Mafemi Crescent, Off SolomonLar Way, Utako District, P.M.B 400 Garki, Abuja.

Headquarters Office, AnnexThe headquarters Annex of National health Insurance Schemeis situated at No 6, Fria Close, Off Adetokunbo AdemolaCrescent, Wuse II, Abuja

Zonal OfficesBENIN: No 1H, Omo Osagie Avenue, Off Sapele Road, OppositeBenin Golf Course, GRA, Benin City.ENUGU: No 5, Ridge Street, Off Okpara Avenue, GRA, Enugu.IBADAN: 15B, Paul Hendricks Road (Tolulope Walls) NewBodija, Ibadan, Oyo State.Fax: 02-2413976ILORIN: Kwara State Ministry of Health, Off River BasinRoundabout, Ilorin, Kwara State.Fax: 031-228682KADUNA: State Secretariat, Independence Way, Kaduna.LAGOS: 443 Herbert Macaulay Way, Yaba, Lagos.Fax: 01-4731182MAIDUGURI: No 3, Shehu Lamini Way, Old GRA, Maiduguri.

ADDITIONAL INFORMATIONFor further enquiries, please contact:Tel: 07098201850 E-mail: nhismedia@yahoo.comNHIS Call Center: 09-4138487 08059282008 08065744100

08024529099 08042318888NHIS Website: www.nhis.gov.ng

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Chapter 9

CONCLUSION

Now, you have been told about the NHIS. You should not just sit on thisinformation. Make use of it. Go to the NHIS office nearest to you and get yourfacility registered. If you have any questions, you can call me on 08036046805,send a mail to hospitalmgt@yahoo.com or visit http://www.hospitalmgt.com.

CHEERS!!

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REFERENCES/SUGGESTED READINGS

Multishield Limited Health Services Manual 1997-2006

NHIS General Rules and Regulations. NHIS Information Unit (2000)

Hygeia HMO Provider Handbook

NHIS Guidelines on Registration. Information Unit (2000)

International Health Management Services Limited Provider Service Manual

NHIS Media Guide

www.nhis.gov.ng