NHIS Nigeria payment mechanisms for primary, secondary and tertiary care
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This document discusses the payment mechanisms used by Nigeria's National Health Insurance Scheme. It outlines that capitation is used to pay primary care providers, fee-for-service is used for secondary and tertiary care, and per diems are paid for bed space. Enrollees pay co-payments for drugs. Payments are made from NHIS to HMOs quarterly and then from HMOs to providers monthly. The document also describes capitation amounts, fee schedules, claims processes and expected returns/reports. Potential abuses of the payment system like delayed payments are also outlined.
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NHIS Nigeria payment mechanisms for primary, secondary and tertiary care
- 1. Payment mechanism B y D r . Y a k u b u A d o l e A g a d a - A m a d e , F R S P H , M N I M D e p t o f S t a n d a r d s & Q u a l i t y A s s u r a n c e , N H I S N i g e r i a NATIONALHE ALTH INSURA NCESCHEME @ J o i n t L e a r n i n g N e t w o r k P r o v i d e r P a y m e n t M e c h a n i s m ( J L N P P M - I T ) M e e t i n g M a n i l a P h i l i p p i n e s J u l 2 8 - 3 1 , 2 0 1 5
- 2. NATIONALHE ALTH INSURA NCESCHEME Different mechanism for different levels of care Mechanisms Capitation for primary care FFS for secondary and tertiary care Per diem for bed space Co-payment for drugs payable by enrolees Co-insurance (partial payments Note Caps and FFS paid into different accounts for purpose of verification – no virement allowed
- 4. NATIONALHE ALTH INSURA NCESCHEME Payment routes All payments through programme managers( HMOs, MHA, CSOs) Quarterly disbursement to HMOs by NHIS (Caps, FFS) Monthly capitation to Providers from HMO Admin charge to HMO Advance payment guarantee bond by HMOs to NHIS
- 5. NATIONALHE ALTH INSURA NCESCHEME Capitation Paid ahead for coverage at primary level N750 per enrolee Paid to HMO quarterly by NHIS Paid to providers 14 days before beginning of covered month on monthly basis by HMOs Actuarially determined
- 6. NATIONALHE ALTH INSURA NCESCHEME Fee-for-service (FFS) Paid by HMOs based on claim by providers N91 per enrolee per month Based on fee schedule/price list Claims to be submitted monthly to HMO within 14 days of provision of service by providers Claims for settlement by HMO within 14 days of receipt HMO to verify claims before payment
- 7. NATIONALHE ALTH INSURA NCESCHEME Co-payment and co-insurance Co-payment 10% of cost of drugs At both primary, secondary and tertiary levels Mainly to discourage moral hazard and also to offset cost Co-insurance Paid by enrolees and HMOs 50% of cost of procedure Usually high tech Inv (CT-Scan, MRI), dialysis etc
- 8. NATIONALHE ALTH INSURA NCESCHEME Returns HMOs expected to make quarterly returns on capitation payment, referrals to NHIS Providers are expected to make returns on caps to NHIS NHIS advises providers on number of lives and capitation due NHIS verifies payment by visits to HMOs/providers HMOs also submits annual statement of account NHIS posseses letters of authority to have access to HMO bank account at any time
- 9. NATIONALHE ALTH INSURA NCESCHEME Abuses of Payment System Delayed payment of capitation Reduced total capitation, reducing enrollee list Non approval of referrals to avoid FFS payment by HMOs Delayed, non-payment of FFS payment Refusal of providers to treat referred patients because of ‘low tariff’ HMOs reducing bills below what is approved in the fee schedule 9