HOSPITALMGT NIGERIA

NHIS: all you need to know

A practical guide for healthcare providers
ohi ohioze

2011

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 FREE this eBook as long as you make no changes or edit its contents. In fact I encourage you to distribute several copies to as many medical and dental practitioners that you know. The NHIS is central to the development of the health sector. Everyone should 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. You make life worth living.

INTRODUCTION
There are several perspectives in understanding the National Health Insurance Scheme. It can be viewed from the regulatory perspective, or from the perspective of a beneficiary. However, I will write this book from the perspective of a Healthcare Provider. The National Health Insurance Scheme (NHIS) is a Social Health Insurance Scheme which was established in Nigeria to subsidize the healthcare costs of Nigerians. As in all Health Insurance Schemes, the healthy are expected to pay for the treatment of the sick. This is done through the pooling together of monthly contributions from the Countrys citizens. A percentage of this amount is paid to the hospitals on a monthly basis. This ensures that funds are always available in the registered hospitals to pay for the treatment of the sick. In my interaction with Medical Doctors, I discovered that a lot of them do not understand how the Scheme works. Though, Doctors know that they are Stakeholders in the Scheme, most do not fully understand their role in the Scheme. Worse still is the fact that a good number of Private Hospitals have refused to tap into this veritable source of income. This may be because they barely understand the scheme or they are reluctant to try something new. I will like to explain to you the basics of the NHIS and how you can participate fully as a Healthcare Provider. The Scheme is awash with funds presently and you have a lot to gain by aligning yourself with the NHIS. Presently, the Public Hospitals have the greatest number of enrollees. This should not be because most Public Hospitals are meant to be Secondary or Tertiary Providers. Nigeria has a huge population (approx.167 million people) that can sustain the Scheme 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 left behind. Before we proceed, let us understand the concept of managed healthcare.
3

Concept of Managed Healthcare

Managed healthcare is the integration of the financing and delivery of healthcare services within a system that seeks to manage the accessibility, cost and quality of that care. As a healthcare provider, you must have at one time or the other encountered situations in which you found it difficult to get patients or you are faced with clients who need healthcare but cannot pay or are reluctant to pay after receiving treatment. Your staff may be going from office to office begging to be paid for services that you have rendered. Conversely, you may be unable to pay your staff salaries at month end or you find it difficult to obtain specialist care for your patients. Under the managed healthcare system, a third party called a Health Maintenance Organization (HMO) elects to seek out interested individuals and Organizations, collects payments from them for healthcare services and contracts with healthcare providers to provide accessible, cost effective and quality healthcare services to their employees and /or dependents. (International Health Management Services LTD Provider Service Manual pp.3). What this simply means is that the HMO contracts with NHIS registered Hospitals who provide healthcare to patients. When the hospitals provide healthcare to patients, they pass the cost over to the HMO. The HMO pays the hospitals with the funds it pooled together from the contributions of the patients. The quality and cost of this healthcare is regulated by the HMO to ensure uniformity across board. With the concept of managed healthcare fully entrenched in your mind, let me show you how you can be a part of the NHIS.

TABLE OF CONTENTS

INTRODUCTION3 HISTORICAL PERSPECTIVE.6 DEFINITION OF TERMS...8 PROGRAMMES AND STAKEHOLDERS.10 HOW YOU CAN BECOME A HCP.13 HOW THE NHIS WORKS18 HOW DO I GET PAID?.......................................................................25 ATTRACTING ENROLLEES28 ZONAL OFFICES.33 CONCLUSION..35 REFERENCES.36

CHAPTER 1
HISTORICAL PERSPECTIVE
The idea of a Social Health Insurance Scheme in Nigeria was first conceived in 1962 by the Halevi Committee. The Committee was set up by the then Federal Minister of Health, Dr. M. A. Majekodumi. The proposal was passed through the Lagos Health Bill in 1962 but was defeated. The idea was again resuscitated in 1984 by the then Minister of Health, Admiral Patrick Koshoni. In 1985, another Minister of Health Dr. Emmanuel Nsan set up a Committee which reported that Health Insurance is viable in Nigeria. Prof. Olikoye Ransome Kuti subsequently raised a consultative Committee on the NHIS in 1988 which recommended an acceptable model for the implementation of the Social Health Insurance in Nigeria. The Federal Government of Nigeria then approved the establishment of the Scheme in 1989. Health Maintenance Organizations (HMOs) were introduced as Financial Managers 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 on October 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 in September 14, 2005. (Formally launched on June 6th, 2005) Presently, the Scheme has over 5million enrollees. There are 61 accredited HMOs, 7,850 Healthcare Providers, 24 Banks, 5 Insurance Companies and 3 Insurance Brokers participating in the Scheme.

The Federal Government is the major participant in the Scheme. Only 2 out of the 36 States in Nigeria have fully rolled into the Scheme. These States are Bauchi and Cross River. About 22 other States are warmly up to enroll their workers in the Scheme. 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 is the reason why you must tap into this goldmine of a Scheme now.

CHAPTER 2
DEFINITION OF TERMS
Lets define some terms that you will encounter in the NHIS. 1. Enrollee: This is an individual who is registered under the Scheme to access healthcare. He may be an employee or a dependant of an employee 2. Capitation: Capitation is a fixed amount payable per enrollee per month irrespective of number of visits or services received within that month. Presently, capitation is N550 per enrollee per month (for public sector) and between N500-N1000 per enrollee per month (for private sector). Capitation is usually paid in advance. The number of enrollees you have determines the number of capitation you receive. A family consisting of father, mother and two children equals four enrollees. So ten of such families equal forty enrollees. Each family is allowed to register only six enrollees. Any additional enrollee is registered separately by the Principal. The Principal is the person who actually pays for the other enrollees. The Principal may be the father or the mother of the family. Capitation is meant to cover primary healthcare. 3. Fee for services: This is the amount that is paid to you for services you provide beyond primary care. It could be surgeries, laboratory services, physiotherapy e.t.c. however, before you provide such services to enrollees, and you must be registered by NHIS to provide secondary care. You must also get authorization from the HMO in charge of such an enrollee. Failure to do this will result in non-payment of your claims. Fee for service payment is based on NHIS tariffs. That means that the NHIS has fixed amounts to be paid for any secondary care you provide. Only with express permission from the HMO can you charge above this tariff.
8

4. Health Maintenance Organization (HMO): This is a private or public Organization which has been registered by the scheme to act as an intermediary between the enrollee and the health care provider. HMOs are mostly private Organizations. They collect contributions from employees and employers. They use some of these contributions to run their affairs, remit some to the NHIS and pay some to the primary care providers as capitations. They also pay for any secondary care provided through the feefor-service. HMOs enter into contractual agreement with the health care providers 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 and registered by the scheme to provide healthcare services to enrollees. 6. Encounter Data: This is the information indicating the enrollee visits to the HCP. You must send monthly reports to the HMO specifying the name of patient, patients NHIS number, diagnosis, treatment and admission days (if admitted).

CHAPTER 3
PROGRAMMES AND STAKEHOLDERS
The aim of the National Health Insurance Scheme is the provision of easy access to healthcare for all Nigerians at an affordable cost through various prepayment systems. This is being achieved through the development of various 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 Government workers for now. As stated earlier, a lot of states have begun to log into the Scheme. When the Scheme is fully operational, it is expected that all the 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.

10

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 Stakeholders
The following are stakeholders in the National Health Insurance Scheme: 1. Government The government sets standards and guidelines which protects the rights and enforces the obligations of all stakeholders. 2. Employees These, together with their dependants are the enrollees (or patients). They contribute 5% of their basic salary to the Scheme. 3. Employers Employers contribute 10% of the basic salary of their employees into the Scheme. They are Public or Private Sector Organizations employing more than 10 persons.

11

4. Health Maintenance Organizations They 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 Providers These are licensed Public or Private Healthcare Facilities which have been registered by the Scheme. They can either be primary, secondary or tertiary healthcare providers. 6. Voluntary Contributors These are people who are basically self-employed. They include the Urban Self-Employed and Rural Community dwellers. 7. Board of Trustees They plan, run and manage the healthcare needs of the voluntary contributors. 8. Other Stakeholders They include: Banks Insurance Companies Professional bodies Insurance Brokers Community Leaders The Media Non Governmental organizations International Organization

12

CHAPTER 4
HOW YOU CAN BECOME A HCP
We have defined the term HCP or Health Care Provider. There are different categories of Providers: Primary, Secondary or Tertiary 1. Primary Healthcare Providers: They serve as the first contact within the healthcare system. They include: 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
13

 Radiotherapy etc.

3. Tertiary HCPs: These are also fee- for service providers. They are basically the Teaching Hospitals. Having understood the different categories of healthcare providers, I advise you register as both a primary and a secondary provider. You will get 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 their addresses later) Step 2: Pick your registration form(s). It cost N5000 to purchase a registration form from the NHIS office. After filling the form you will pay N10, 000 to be accredited as a Primary HCP. For the secondary providers, you are expected to pay an additional N10, 000 per specialty you 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 a Primary HCP. This will ensure that your patients do not have to go outside your facility to access these services. Step 3: Fill the form(s) appropriately and return it/ them to the NHIS office. Step 4: Ensure you meet all their requirements (more on this later) Step 5: NHIS and HMO Officials will inspect your Facility

14

Step 6: if you meet their requirements, you will be issued a Registration Certificate(s) and NHIS poster. You are to conspicuously display the Poster in your Facility. Step 7: Sign contractual agreements with HMOs. You can sign with as many HMOs that approach you. There is no limit to the number of HMOs that you can relate with. NB: You need to sign with as many HMOs as possible because each HMO has a specific segment of the society that it covers. For example, a HMO may cover workers from the Federal Ministry of Transport only; another may handle the Police Force and Immigration Services. So the more HMOs you sign with, the greater the potential number of enrollees you will get. Step 8: After signing the necessary documents, you will receive your enrollee list along with your capitation payment. (Capitation is paid directly into your bank account or through bank cheques sent to you quarterly). 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 details with each HMO. You should have separate official files for each HMO where you keep their letters and other correspondences between you. NB2: Assign an administrative staff to manage this information. As the years go by, your files will become quite bulky and difficult for you to manage alone. The registration process may take between 2-3months. So, commence it today!

15

Private Hospitals Registration Guidelines Depending on your status- either primary or secondary, the following guidelines 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 size of an average sitting room) which should contain sitting facilities, reception and registration table and medical records keeping Facilities. Consulting room measuring 4x3metres with examination couch, equipment for complete physical examination, running water and hand towels. Treatment room also measuring 4x3metres with instruments cabinet, dressing and injection trolley and equipment, running water 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 Doctors room
16

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 of registration with their Professional Association. All staff should also be covered with a malpractice Insurance. You can get this Insurance Policy from NICON Insurance or IGI Insurance Company. You also need a Malpractice Insurance Policy to cover your facility. This will not cost much. You can actually take a policy of N1.5 million which is the minimum required. You will then pay a premium 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 conducive environment Provide education to enrollees and the community about the Scheme Gather information on the Scheme and send this information monthly to NHIS and HMOs. Now, lets see how the Scheme works.
17

CHAPTER 5 HOW THE NHIS WORKS

After accreditation the NHIS will provide you with two very important documents-the NHIS Essential Drug List and the NHIS Fee-For-Professional-Service Tariff. The Drug List is the same as the National Essential Drug List but in addition, it contains fixed prices for each drug. This is meant to guide you when calculating the cost of drugs you prescribe. The Fee-for-service Tariff contains a list of all the procedures approved by the Scheme along with their 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 lists and professional tariffs. These are essentially derivatives of the NHIS documents. There are a few differences especially for the Organized Private Sector Schemes. Now that your hospital has been accredited, how do you go about attending to the enrollees? First, you will receive an enrollee list with the enrollee photo panel from all the HMOs you have signed agreement with. Each photo panel will contain the photographs and names of a particular family. You are advised to open an individual folder for each enrollee and attach the photo panel to the inside-front cover of the folder. I will also advise that you create a register/database containing the names of all your enrollees regardless of HMO. Most enrollees do not know what HMO means and who their HMO is.
18

So trying to identify them by HMO may be difficult. Compile the database/comprehensive register of the enrollees as the names are sent to you from their different HMOs. Next, when an enrollee comes for healthcare, you should identify the enrollee. Note that you must not allow an enrollee to bring his friend, or mother, or uncle who is not registered. Giving treatment to such a patient under the Scheme will defeat the purpose of the Scheme and reduce your profit margin. However, as a healthcare provider you should encourage such a patient to have his/her own separate folder and pay out of his/her pocket for 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 patient with 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 enrollees name is in the NHIS list. (d)Call HMO: Finally, you can call the HMO to confirm enrollee eligibility. NB: For registered patients (with HMO ID Cards) who present in emergency but whose names are not on your list, you can render immediate resuscitative services and notify their HMO within 24hours.The HMO will give you a treatment authorization code. The HMO will usually pay you on a fee-for-service basis for such patients when you present the bill and the authorization code. After identifying enrollee and confirming eligibility, the patient should fill the attendance form. After this, you render the appropriate service to the enrollee. NB: However, there are some exclusions to the type of services you can provide. These exclusions are occupational/industrial
19

injuries, terminal illness including all cancers, overseas treatment, infertility treatment, cosmetic surgery etc. After attending to the enrollee, please fill the NHIS prescription form. The enrollee then takes the prescription to your pharmacy (if it is accredited) where the cost of the drugs are calculated according to NHIS Drug List. The patient then pays 10% of the cost of the drugs and is given his/her drugs. E.g. if your prescription is: Tabs Ciprofloxacin 500g b.d x 1/52 Tabs Diclofenac 50mg b.d x 5/7 According 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.

Referrals
Under the Scheme, when a patient requires secondary care e.g. appendectomy, he/she should be referred to a secondary provider (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 provider to your facility. Call the enrollees HMO Hotline/Emergency line to get an authorization code.

20

 Fill the referral form provided by the HMO or NHIS. Ensure you clearly write the authorization code at the top of the form. Give the referral form to the enrollee and send him/her to the 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 the referral form. HMOs do not like paying for the same investigation twice. If you are accredited for secondary care, you are expected to also follow the steps above. The only difference is that you are referring the enrollee to yourself. You will need to carry out the above referral steps so that your claims can be paid. At the end of the month in which you provided the secondary care to the enrollee, you are expected to calculate your fee-for service (based on the NHIS guidelines) and send your claims form to 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. The remaining 90% is calculated along with the cost of procedure and paid as fee-for-service by the HMO. NB 2: Also note that any secondary care provided without authorization from the HMO will not be paid. Any bill computed without following the NHIS or HMO guidelines will also not be paid. NB 3: If the case is an emergency, you are expected to go ahead with the procedure and notify the HMO within 24 hours. The HMO hotlines are open 24 hours of the day and 7 days of the week.
21

Lets 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 she consented to. You are a secondary provider in Obstetrics & Gynecology. Step 1: Call her HMO e.g. Goodhealth HMO Ltd and notify them of the surgery. Furnish them with her details; name, NHIS ID number, bio data, reason for surgery etc. Step 2: The HMO gives you an authorization code e.g. HMO 097/301212/AX 0032/S Step 3: Fill the referral form accordingly Step 4: Fill the consent form and carry out the surgery. Ensure mother and child are fine. Step 5: After discharge, you calculate the fee for service as follows: Antenatal Care N5, 000 Ultrasound Scan N1, 000 Specialist Initial Consultation N1, 000 Specialist Review (3 days) N3, 000 Nursing Care (4 days) N2, 000 Surgery N40, 000 Drugs N15, 000 Total N67, 000 NB: This bill is based on the NHIS Fee for Service Handbook and NHIS Drug Price List (2005). NB2: You are expected to send a list of the drugs used post-op (as well 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 Courier Service. Step 8: Expect your cheque within 4 weeks.
22

Out of Station Care

An enrollee may require urgent care outside his/her usual state of residence. This is called Out of Station Care. In such cases, the provider is expected to treat the enrollee after confirming his/her eligibility status. You can confirm eligibility status through the Enrollees ID card and by calling the HMO to get an authorization code. At the end of the month, the referral forms (claim form, authorization form e.t.c) are filled and sent to the HMO for settlement of claims.

Relationship with Other Stakeholders

As a provider, you should have a good relationship with other stakeholders particularly the Enrollees, HMOs and NHIS. (I will discuss relationship with Enrollees in another chapter) In relating with the NHIS, you are expected to provide a desk and chair (or an office) in your Facility for the NHIS focal person in your state. The NHIS focal person is usually sent from the Zonal Office to monitor the healthcare providers. You are expected to furnish the focal person with monthly Enrollees records, monthly/quarterly capitation payments records and a host of other records. The focal person may request to go through your records at any time and you are meant to oblige him/her. The focal person also handles issues and/or disputes arising between enrollees and HCPs or between HMOs and HCPs. Your relationship with the HMOs begins from the point of signing the bilateral contractual agreement. The HMO has the right to inspect your facility, go through patients records and scrutinize your bills. You are expected to seek authorization from the HMOs before providing/referring enrollees for secondary care. You
23

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

24

CHAPTER 6
HOW DO I GET PAID?
I have already explained the payment methods in the Scheme. Public Sector Payment Methods The methods used for payment in the public sector are the monthly capitation payments and the fee for service payment. You should also know that an enrollee is entitled to be admitted into your facility for not more than 15 days per year. The HMO is expected to pay for any extra number of days the enrollee spends on admission. Capitation is usually paid quarterly( in advance). Capitation is N550 per enrollee per month. Fee-for-service is paid within 4 weeks of submission of claims. (Though most HMOs will insist that they will pay your claims within 14 days). Private Sector Payment Methods The capitations paid in the Private Sector Scheme depend on the enrollee 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. In the private sector scheme, capitation is usually paid to providers with 51 or more enrollees. For providers with less than 51 enrollees, payment is made through the Diagnosis Related Tariff. This is a list of payment amounts related to different diagnosis.eg there is a fee paid for the treatment of uncomplicated malaria. There is another fee paid for treating bronchopneumonia and so on.

25

Providers are also paid through Fee-For-Service in the Private Sector Scheme. Some HMOs actually use this method more than the other two methods. You may wonder how the Scheme can be said to be lucrative when capitation is just N550 per enrollee per month. I am going to show you (through a Hospitals NHIS records) the profit potentials of the Scheme. Dont ask me how I got the records, just study them and see for yourself. It is the payment and visitation record for a modest HCP with about 500 enrollees. Table of NHIS Records for Hospital X (Jan Sept, 2007) Month Total No. No of % of Monthly Amount Balance of enrollees enrollees capitation Spent (N) Enrollees that that (N) (N) visited visited HCP (approx.) January 543 36 7 298,650 56,960 241,690 February 543 39 7 298,650 55,017 243,633 March 548 50 9 301,400 73,900 227,500 April 548 44 8 301,400 68,500 232,900 May 562 51 9 309,100 75,420 233,680 June 562 57 10 309,100 85,110 223,990 July 567 52 9 311,850 83,750 228,100 August 567 51 9 311,850 89,993 221,857 September 560 60 11 308,000 98,557 209,443 Total 5,000 440 9% 2,750,000 684,207 2,065,793 From the table above, hospital X had 5,000 registered enrollees in nine months. Only 440(9%) of those enrollees assessed care in 9 months!! These 440 enrollees also include patients who visited the 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

26

made a profit of N2, 065,793(75%) in 9 months. Note that this is just one of the sources of revenue of Hospital X. NB: Hospital X also had about 900 private enrollees (in the 9 months period) not captured in the table above. NB2: Revenue derived from fee-for-service was also not added to the table. You can therefore appreciate the profit potential of the Scheme. It is a ready source of hospital revenue. You no longer have to think of how to pay staff salaries. Every month, a certain amount of money called capitation is paid into your hospital account. This is irrespective of the fact that the enrollee accessed care or not. However, looking at Hospital Xs table, you will realize that out of 9% utilization, the hospital spent 25% of its capitation. This means hospital X is probably using expensive branded drugs for its enrollees. This 25% can be reduced by adhering strictly to the NHIS Drug List which favors generic drugs over branded drugs. I am quite sure that the same profit scenario is repeated in so many HCPs. Imagine a HCP with over 10, 000 enrollees!! That is actually the lot of most Public Hospitals. The Private Hospitals should therefore sit up and get their own share of the NHIS cake. The secret to good profit in the Scheme is the number of enrollees you have. A Hospital with less than 50 enrollees will probably not make much profit. I shall discuss how to attract enrollees to your facility soon. A word of caution is needed here. The profit derived from the Scheme is not meant to be spent on personal excesses. You should re-invest it into your facility to purchase standard equipment, erect standard buildings, and hire qualified personnel etc. This profit must be seen to make a positive difference in your facility. With such an amount, you can effectively plan ahead for your hospital. You can go back and read the chapter on Planning and Control in the book Hospital Management Made Easy.
27

Chapter 7 ATTRACTING ENROLLEES

To realize the profit potential of the Scheme, you need a large number of enrollees. Most Insurance people will tell you that the more customers they have the more profit they make. Think of your car insurance policy. It is mandated by law. You pay premium every year. So do millions of other vehicle owners in the Country. How many times have you made a claim to your insurance company? (Lets not talk about all the processes you go through before your claim is paid). My guess is that you have never made any claim. The point is what happens to all that money? The huge resources in the insurance industry go somewhere. I wont say where. The secret of generating this revenue is the customer base. Get the customers to come, you get the cash. I will show you several things that you need to do to help you attract (and retain) enrollees to your hospital. 1. Honesty A friend of mine who is an enrollee based in Ibadan changed providers twice in less than 2 years. Even with the second provider, he refused to utilize the facility more than four times. He eventually moved out of Ibadan and changed his HCP to his new location. What was his grouse? It was Dishonesty! His first HCP lied that the NHIS only pays for drugs like chloroquine in treating malaria. He was also told that payment was not regular. He was often billed above the 10% fee he was supposed to pay. Those two facilities lost 6 enrollees because of dishonesty.
28

The first advice I will give to you is to be honest. Enrollees are attracted to facilities that are honest and forthright. Nobody likes being cheated (no matter how small the amount). If the Scheme says the bill N950, collect N95 (10%) only from the enrollee. Do not increase it to N150. Enrollees frequently compare notes with each other. They will know when they are being cheated and they will leave you for honest HCPs. 2. Adhere to NHIS Guidelines This is closely related to the point above. Please follow the NHIS guidelines as much as possible. Dont collect more than the stipulated charges. Dont give substandard drugs. 3. Prompt Service The main reason why patients seek private healthcare is that they want to receive prompt attention. Render prompt services. Enrollees do not want to wait on endless queues before they can access healthcare. Try to reduce your patient waiting time at each point of the hospital process (Get my book, Understanding Private Practice). When you render prompt services, enrollees will be attracted to your facility.

4. 24 Hour Services In addition to rendering prompt services, you can go a step further and keep your doors open for 24 hours. NHIS enrollees can come to your facility at any time. If there is no doctor to attend to them, they will eventually transfer to another facility. We recently lost some enrollees to another HCP because there was no doctor-on-call the night they came. We have since corrected that anomaly. Patients have greater confidence in your facility when they know that they can access care even at 2am.
29

5. Friendliness and Courtesy A popular saying goes He who wants friends must first make himself friendly. The hospital staff must be friendly and courteous at ALL times. Your hospital environment must be welcoming. The patient should feel at ease when he/she visits your facility. From my interaction with NHIS enrollees, I discovered that they want to be treated as the nouveux rich-the best thing in healthcare. Therefore your ability to make them feel important will give you an edge over others in attracting enrollees. Change your attitude from the harsh, stern faced, no nonsense doctor to that of a loving, caring and hospitable healthcare provider. Beware, however of pampering enrollees. It could be counter- productive. 6. Existing Patients You will probably have an initial patient base before you register with the Scheme. You should consciously preach the gospel of NHIS to such patients. A lot of State Governments are coming onboard; also the urban self-employed Social Health Insurance Scheme is about to kick-off. These patients have been accessing healthcare somewhere before the Scheme started. That somewhere may be your facility. Encourage such patients to register with the Scheme and choose your facility so they can continue their existing relationship with you. Make them see the benefits of remaining in your Facility. Convert them. Note that if you have not being good to them in the past, they will probably see this as an opportunity to run away from you. However, most patients will still choose your facility due to customer loyalty.

30

7. Hospital Evangelists Hospital Evangelists are enrollees that inform other patients (their co-worker, neighbors, friends e.t.c) of the goodies they enjoy in your Facility. They will definitely boast of the superiority of their HCP to their friends. Try to identify such enrollees and actively encourage them to attract other enrollees. You can do this simply by giving them quality services. You dont necessarily have to say to them bring your friends. Your good actions will be louder than your words.

8. Quality Success has many parents but failure is an orphan. Give good quality services and you will attract enrollees. Give poor quality services and you will repel enrollees. Read the chapter on Total Quality Management in my book Hospital Management Made Easy.

9. Specialist Clinics One of the major reasons why enrollees prefer public hospitals over private hospitals is because of the somewhat erroneous belief that they will get access to consultants in the public hospitals. This belief is only partly true. First, most enrollees do not need specialist care at all and can be treated at the primary level (private hospitals). Secondly, Consultants are definitely not the first doctors to see patients in public hospitals. This is usually left for other junior doctors. Thirdly, a consultant will give a patient more time and attention in a private facility than in a public facility where he has a long line of patients waiting to see him.
31

Healthcare workers know this but most enrollees dont. So while you are still trying to educate enrollees, offer them prompt specialist services when needed. However, you need to have been accredited by the NHIS for such specialist services. The key therefore is to get your hospital accredited for specialist (secondary) care and to inform enrollees about your status as a secondary provider. This will boost their confidence in your facility and attract other enrollees. Make sure that you actually get a specialist to render secondary care.

10.Discipline and Persistence In the final analysis, you need discipline and persistence to succeed in any business venture. Attracting enrollees takes time and you have to keep at it. Apart from public hospitals that do little or nothing to attract (and retain) enrollees, every private hospital on the Scheme has to keep on working. Dont quit. Winners dont quit and quitters never win. Enrollees may leave your facility for several reasons e.g. those who attain the age of 18, those who transfer out of town, and those who may have lost confidence in your facility etc. But you must ensure that for every single enrollee that leaves, you attract 10 more. Use the information contained in this book. I assure you that if you 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. Visit www.hospitalmgt.com.

32

Chapter 8
ZONAL OFFICES
It will be a waste of time if you have gone through this book and yet do nothing. Any information received that is not put to use becomes useless. Procrastination is a potent killer of vision. So I am going to give you the contact addresses of the NHIS Headquarters and Zonal Offices. I want you to get your hospital registered today!! The journey of a thousand miles actually begins with one simple step. The NHIS has offices in all six geopolitical zones of Nigeria. In addition, the headquarters is in Abuja. States that have fully rolled into the Scheme has NHIS Offices. Such States are Bauchi and Cross River. All other states have an NHIS focal Person or Desk Officer. These Officers have been sent from the Zonal Offices to ensure the smooth running of the Scheme. Usually, every registered HCP should provide office accommodation for the desk officer. The Desk Officers spend their time amongst the different HCPs on a daily or weekly basis. To contact them, go to any of the HCPs in your area and ask for the NHIS Desk Officer. However, because of the large enrollee population in Government Hospitals, they spend most of their time there. You are most likely to meet them in Public Hospitals.

33

ADDRESSES Headquarters Office The Headquarters of the National Health Insurance Scheme is located at Plot No. 297, P.O.W Mafemi Crescent, Off Solomon Lar Way, Utako District, P.M.B 400 Garki, Abuja. Headquarters Office, Annex The headquarters Annex of National health Insurance Scheme is situated at No 6, Fria Close, Off Adetokunbo Ademola Crescent, Wuse II, Abuja Zonal Offices BENIN: No 1H, Omo Osagie Avenue, Off Sapele Road, Opposite Benin Golf Course, GRA, Benin City. ENUGU: No 5, Ridge Street, Off Okpara Avenue, GRA, Enugu. IBADAN: 15B, Paul Hendricks Road (Tolulope Walls) New Bodija, Ibadan, Oyo State. Fax: 02-2413976 ILORIN: Kwara State Ministry of Health, Off River Basin Roundabout, Ilorin, Kwara State. Fax: 031-228682 KADUNA: State Secretariat, Independence Way, Kaduna. LAGOS: 443 Herbert Macaulay Way, Yaba, Lagos. Fax: 01-4731182 MAIDUGURI: No 3, Shehu Lamini Way, Old GRA, Maiduguri. ADDITIONAL INFORMATION For further enquiries, please contact: Tel: 07098201850 E-mail: nhismedia@yahoo.com NHIS Call Center: 09-4138487 08059282008 08065744100 08024529099 08042318888 NHIS Website: www.nhis.gov.ng
34

Chapter 9
CONCLUSION
Now, you have been told about the NHIS. You should not just sit on this information. Make use of it. Go to the NHIS office nearest to you and get your facility 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!!

35

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

36