Health Insurance Unit

HEALTH INSURANCE UNIT(HIU):

Federal Medical Centre, Yenagoa, Bayelsa is an accredited provider of primary and specialized (secondary and tertiary) care to over 16,000 enrollees under both the National Health Insurance Authority (NHIA) & Private retainerships schemes.
The Health Insurance unit is responsible to coordinate all social and private health insurance programmes of the hospital in order to create excellent service value for those seeking care through those programmes while ensuring optimal cost recovery.

[A] Offices:

i. Enrollee waiting area
ii. Triage room
iii. Nurses’ station
iv. Consulting rooms
v. Pharmacy unit
vi. Other Administrative offices (HOU, Admin manager, Primary care desk, Secondary care desk, Standard and Quality Assurance desk & Claims management office)

[B] Operations:

1. 1. Enrollee verification.
   2. Clarify purpose of visit and proceed accordingly.
   3. Ensuring pre-authorization codes verification, generation, documentation and updating for referrals to specialists are done.
   4. Issuance of authorization for approved services.
   5. Tracking of enrollee stay and use of services in alignment with operational guidelines and MOUs.
   6. Ensure maximum enrollee satisfaction; Document, communicate and help resolve enrollees’ complaints.
   7. Track in-Enrollees’ referrals and procedure (Clinics, wards and theater).
   8. Submission of monthly encounters to HMOs.
   9. Ensures that claims are compiled and sent to HMOs in line with NHIA and Private retainerships operational guideline timelines.
   10. Ensure that claim compilates are optimal,
   11. Ensure that HMOs are monitored and tracked on payment of capitation and claims for fee-for-service.
   12. Ensure that Claims payment review is done to account for shortfalls
   13. Provide feedback to the other desk operations on outcomes from claims review and support Enrollee discharge process (Hospital claims)
   14. Maintaining records of inflow/income of the all-Health Insurance programmes.
   15. Maintain relevant records for all unit operations; Review of Data
   16. Coordinate Medical fitness programmes for individuals/organizations
   17. Update and sensitize hospital community on operational reforms to strengthen the Health insurance value chain
   18. Administrative and Clinical supervision of the FMC Yenagoa NYSC Primary care camp clinic
   19. Carry out logistics related to secretarial/administrative functions in the Unit.

[C] Staffing:

1. 1.  Doctors: Head, HIU(Consultant); Ass. Head (Consultant), Medical Officers & Resident doctors.
   2.  Nurses: Chief Nursing officers and other Nursing officers.
   3.  Desk Officers: Program Analysts, Scientific, Administrative, Clerical, Health information, Planning etc
   4. Support Staff: Facility manager, Health Assistants, etc

[D]. Procedure for Accessing Services:

1. 1. All enrolees (and their dependants) must first present at the Health Insurance complex.
   2. Verification is conducted to determine if an eligible NHIA or Private retainership client
   3. The healthcare service to be accessed is then determined to be Primary or Specialized.
   4. IF Primary care required, Enrollee is issued an Authorization slip: Primary care services are domiciled in FMC Yenagoa at:
      • Primary care clinic (PCC), Health Insurance Unit Complex for all Adults
      • General paediatrics clinic, for all Paediatric Enrollees
      • Ante-natal clinic for all uncomplicated cases
      • Accident & Emergency (A/E) & Surgery out-Enrollee department (SOPD) for minor procedures
   5. Enrollee proceeds to the Health Information Department and is registered and issued E-PID number.
   6. Enrollee is sent to triage station for nurses to record vitals and then to the doctor for consultation. At the end of whish
   7. Enrollee may be asked to obtain: with either or a combination of the following:
      • Admission into the wards (Secondary care protocol is initiated)
      • Drugs from the Health Insurance pharmacy unit.
      • Clinical investigations in the medical laboratory, radiology, specialist services and referral cases as directed by the doctor.
   8. All Enrollees access healthcare from the primary level of care, except those who have referral letters from their primary healthcare providers.
   9. Enrollees may remain and complete treatment at the primary level of care according to the doctor’s diagnosis. Such Enrollees will proceed to the desk office for clearance before proceeding to the NHIA pharmacy unit, where the prescribed drugs will be priced and 10% co-payment will be written out for Enrollees to pay at the hospital approved pay-point in the Centre.
   10. All investigations from the medical laboratory services department are 100% free at the primary level of care but not all are covered at the secondary level of care.
   11. Enrollees may also be referred for secondary level of care for expert review and management in the specialist clinics/units. This will also require authorization codes from their respective HMO before proceeding to the referred clinic/unit.
   12. IF for Secondary/ Specialized care is required, the Enrollee is directed to the secondary desk for code verification, generation and updating as applicable before proceeding for specialist consultation with the authorization slip bearing the details and scope of secondary care.
   13. Pre-Approval by the Health Maintenance Organisation (HMO) is necessary, except in emergencies when authorization should be sought within 48-72hrs of commencement of treatment.
   14. Enrollee admitted into the ward is covered under NHIA for 21 days cumulatively for a year. Enrollee also continues with 10% co-payment for all drugs covered by the NHIA.
   15. Co-payment variations exist for enrolees under Private health insurance and will be communicated accordingly.
   16. No Health insurance Enrollee shall be treated or examined or discharged without reporting to the Secondary care desk office for clearance and authorization.
   17. Authorizations are only valid for 24hours.
   18. The Health insurance unit (HIU) does not receive and collect any form of payment directly from Enrollees. All payments are directed to the hospital’s approved pay points within the Hospital.

[E] Working Hours: 24hrs; Public holidays inclusive.

[F] Details of Complaints/Grievance Redress Mechanism:

1. Complaints should be made directly to the Standard and Quality Assurance desk officer domiciled at the Secondary desk office.
2. The complaints/Suggestion box may also be used where anonymous submission is preferred.
3. Inform the HIU Head of unit or Supervisors
4. Lodge complaint with SERVICOM office.

[G] Limitations:

1. Need to decentralize HIU Secondary care operations for improved Enrollee experience and programme efficiency and effectiveness
   • Need for more consulting rooms and office spaces for Enrollee and staff
   • Need for unlimited internet access for desk operations
2. Primary and Secondary desk operations:
   • Need for Office equipment to include chairs, tables, computer systems
3. Claims management:
   • Difficulty in compiling claims and high level of Underbilling to HMO Diagnoses not tallying with requested investigations and prescribed drugs
   • High levels of shortfalls and vetted out claims
   • Delayed payment by HMOs.
4. Hospital Service delivery points:

• • Poor gatekeeping by health providers at the various service delivery points
  • Specialist care provided in Primary care clinics
  • Poor clinical documentation (limited capture of procedures in clinic and beside)
  • Challenges in separating secondary cases from primary cases on the EMR.
  • Poly-consultation, Unauthorized cross specialty investigations and polypharmacy