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MedPublic Healthcare MedPublic Healthcare was founded on a commitment to health equity. Disadvantaged populations bear the brunt. MOTTO
Fostering equitable access to healthcare.

Our mandate is to mitigate the impact of healthcare challenges and build healthier communities. In Nigeria, persistent barriers to quality care—including a shortage of doctors and insufficient political will—have led to an unnecessary disease burden and preventable deaths. Our mandate is to mitigate the impact of these challenges and build healthier communities. VISION
To foster equitable access to high-quality, affordable healthcare; eliminating disparities, and empowering disadvantaged populations to achieve their fullest health potential. MISSION
To develop sustainable, innovative solutions for equitable access to high-quality, affordable healthcare.

Profiting from HMO Partnerships: Minimizing HMO Debt Burden - Part OneWelcome! We kick off our series on minimizing HMO ...
06/04/2025

Profiting from HMO Partnerships: Minimizing HMO Debt Burden - Part One

Welcome! We kick off our series on minimizing HMO debts.

Get ready to learn how to secure early payments from your HMO partners!

BEFORE SIGNING

Step 1: Know Thy HMO

- Research the HMO's payment history and reputation; don't rush into signing that contract!
- Review their financial stability and creditworthiness; beware of red flags.
- Don't hesitate to ask tough questions – it's like courtship; get to know them before committing.

Step 2: Negotiate Like a Pro

- Clearly outline payment terms, schedules, and methods; take the driver's seat.
- Define dispute resolution processes; know your rights.
- Establish open communication channels; identify key contacts for quick resolutions.

Key Considerations:

- Consider involving your lawyer to demonstrate professionalism and strength, deterring HMOs with unhealthy motives.
- Already have an unfavorable deal with the HMO? Renegotiate using the steps above.
- Hiring an HMO expert can help secure an excellent deal.

That's all for now. Join us next week for Part Two!



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Profiting from HMO Partnerships: Minimizing HMO Debt Burden - IntroductionOver the next few weeks, we'll explore effecti...
07/11/2024

Profiting from HMO Partnerships: Minimizing HMO Debt Burden - Introduction

Over the next few weeks, we'll explore effective strategies to minimize or eliminate Health Maintenance Organizations' indebtedness to your facility.

As an HMO professional with over seven years of experience, I've observed that many healthcare providers struggle to manage HMO debt. Common approaches, such as relaxed payment terms or service suspensions, often prove ineffective.

Contrary to popular belief, HMOs are generally willing to pay. However, internal dynamics and external factors can influence payment timelines.

In this series, we'll focus on empowering healthcare providers to optimize debt recovery. You'll learn how to:

- Negotiate favorable terms
- Streamline payment processes
- Monitor and address potential issues

Get ready for valuable insights and practical tips to ensure timely payments from your HMO partners.

Join me next week for the first installment of this informative series.



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Profiting from HMO Partnerships: Minimizing Losses from HMO Clinical Audits - Part Four (Retrospective Audits)We continu...
07/11/2024

Profiting from HMO Partnerships: Minimizing Losses from HMO Clinical Audits - Part Four (Retrospective Audits)

We continue our series on HMO Clinical Audits as we discuss the last topic, Retrospective Audits.

In retrospective audits, enrollee records are reviewed after treatment to assess quality and adherence to guidelines.

Pre-Audit Preparation

1. Verify Enrollee Data: Ensure enrollee information accuracy.
2. Document Thoroughly: Maintain detailed medical records.
3. Accurate Authorization Code Record: All secondary service codes should be properly and accurately documented.
4. Comply with HMO Guidelines: Understand and adhere to specific HMO regulations.

During Audit

1. Prompt Response: Address audit notifications quickly.
2. Organize Records: Ensure records are complete and accessible.
3. Appeal Unjustified Denials: Contest unwarranted claims denials.
4. Negotiate Settlements: Resolve disputes efficiently.

Post-Audit Actions

1. Analyze Audit Findings: Identify areas for improvement.
2. Implement Corrective Actions: Address weaknesses.
3. Monitor Progress: Track changes and ensure sustainability.
4. Maintain Transparency: Ensure open communication among staff.

Other Recommendations

1. Designate an Audit Coordinator: Centralize audit management.
2. Engage Experts: Consult with audit specialists.
3. Stay Updated on Regulations: Continuously educate yourself on changing guidelines.
4. Foster a Compliance Culture: Encourage accountability.

Proactive measures and effective audit management minimize financial losses, ensuring healthcare providers financial stability.



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Profiting from HMO Partnerships: Minimizing Losses from HMO Clinical Audits - Part Three (Concurrent Audits)We continue ...
02/11/2024

Profiting from HMO Partnerships: Minimizing Losses from HMO Clinical Audits - Part Three (Concurrent Audits)

We continue our series on HMO Clinical Audits, focusing on Concurrent Audits. This process involves real-time review of enrollee care during hospitalization or treatment.

Strategies to Minimize Financial Losses During Concurrent Audits

Pre-Audit

1. Verify enrollee coverage and policy limits.
2. Ensure secondary services have authorized codes documented correctly.
3. Maintain accurate records of rendered care.

During Audit

1. Designate a single point of contact, ideally staffed by medical personnel.
2. Provide prompt access to enrollee records.
3. Address auditor inquiries and concerns promptly.

Post-Audit

1. Review audit findings and recommendations.
2. Implement corrective actions.
3. Clarify ambiguous issues with the HMO.

Additional Best Practices

1. Regularly review and update HMO policies and procedures.
2. Conduct internal audits and train staff.
3. Maintain open communication with HMO auditors.

By following these guidelines, healthcare providers can minimize financial losses and ensure seamless audit processes.



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Profiting from HMO Partnerships: Minimizing Losses from HMO Clinical Audits - Part Two (Prospective Audits)Today we woul...
07/10/2024

Profiting from HMO Partnerships: Minimizing Losses from HMO Clinical Audits - Part Two (Prospective Audits)

Today we would be considering how to limit losses from HMOs' prospective audits.

A prospective audit evaluates an enrollee's coverage, relevance of treatment (medical necessity), and other factors, before care is authorized.

To minimize financial losses during prospective audit processes consider the following strategies:

- Verify enrollee eligibility and coverage.
- Confirm benefits and limitations.
- Review medical necessity criteria.
- Submit any required document promptly.
- Obtain pre-authorization for treatments.
- Monitor authorization expiration dates.
- Promptly resolve grey areas with HMOs.

Other considerations:

- Maintain accurate and complete enrollee medical records.
- Utilize updated HMO tariffs.
- Regularly review HMOs' policy changes and/or updates.
- Educate staff on prospective audit processes.

It is vital to note that most prospective audits within the Nigerian managed care setting occur before authorization codes are issued.



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Profiting from HMO Partnerships: Minimizing Losses from HMO Clinical Audits - Part OneLet us delve into how you can limi...
30/09/2024

Profiting from HMO Partnerships: Minimizing Losses from HMO Clinical Audits - Part One

Let us delve into how you can limit those financial losses from HMOs' clinical audits.

Clinical audit is an integral part of managed care. In Nigeria, it is mandated under the National Health Insurance Authority (NHIA).

Understanding clinical audits from HMOs' perspective would save your facility lots of money.

Why do HMOs need to audit?
- To reduce operational costs
- To improve quality of care
- To ensure compliance to relevant guidelines
- To identify areas for service improvement

Broadly speaking, especially in Nigeria, there are three main types of clinical audits:

- Retrospective Audit: Reviews enrollee records after treatment to assess quality and adherence to guidelines.

- Concurrent Audit: Real-time review of enrollee care during hospitalization or treatment.

- Prospective Audit: Evaluates the enrollee's coverage, relevance of treatment, and other factors, before authorizing care.

In the next post, we will highlight specific steps to take to limit losses from HMO audits.



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Profiting from HMO Partnerships: Minimizing Vetting on Your ClaimsHello Healthcare Provider!Are you tired of the bills s...
21/09/2024

Profiting from HMO Partnerships: Minimizing Vetting on Your Claims

Hello Healthcare Provider!

Are you tired of the bills slashing by HMOs? If yes, then the tips below are for you!

1. Unbiased Claims Preparation: Approach claims preparation with a neutral mindset, avoiding assumptions about potential bill slashing. This ensures a fair and accurate representation of services rendered.

2. Tariff Management: Regularly update and utilize favorable tariffs with your HMO partners to ensure accurate settlement.

3. HMO Policy Understanding: Invest time in understanding each HMO's unique billing policies, protocols, and processes. This knowledge enables effective claims preparation and minimizes errors.

4. Authorization Code Management: Ensure timely obtainment and use of necessary authorization codes for services requiring them, preventing unnecessary delays or rejections.

5. Medical Review: Engage a doctor to review claims before submission, verifying accuracy and justification of treatments. This critical step ensures compliance and reduces the risk of vetting.

By implementing these strategies, you can optimize your facility's partnerships with HMOs, streamline claims processes, and maximize revenue.



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It's common knowledge that the awareness of managed care benefits is not widespread in developing countries. Unlike the ...
16/09/2024

It's common knowledge that the awareness of managed care benefits is not widespread in developing countries. Unlike the familiar out-of-pocket payment practice, managed care (or health insurance) is mostly well structured and coordinated. Unknown to many, being under managed care has loads of benefits. So, I thought I should do a quick summary on the subject.

First, managed care helps to control healthcare costs by negotiating discounted rates with healthcare providers, managing utilization of services, and promoting cost-effective treatments. In addition, by organizing and coordinating healthcare services, patients have access to a network of healthcare facilities, which naturally leads to reduction of barriers to care.

Similarly, there is intentional coordination among different providers, which helps with the continuity and quality of care. Also, most managed care programs have structured quality improvement initiatives, such as accreditation standards and performance measurement.

There is emphasis on preventive care and wellness programs, which can help identify health risks early, prevent the onset of diseases, and promote healthier lifestyles among registered beneficiares. Beneficiaries also receive health education and support services to empower them to make informed decisions about their health and healthcare options.

It's obvious that the rising cost of healthcare threatens healthcare quality and affordability. Since, managed care helps to mitigate this dilemma, I strongly believe that it's worth embracing.



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It's not possible to talk about managed care in Nigeria without talking about the National Health Insurance Scheme (now ...
16/09/2024

It's not possible to talk about managed care in Nigeria without talking about the National Health Insurance Scheme (now the National Health Insurance Authority).

The National Health Insurance Scheme has the task of providing health insurance coverage to all Nigerians and legal residents. By implication, the body is meant to protect citizens and residents from financial hardship due to out-of-pocket healthcare expenses. In essence, NHIS aims to achieve Universal Health Coverage (UHC). NHIS also regulates health insurance in Nigeria. The body accredits and regulates the activities of all state-run health insurance programs and private HMOs.

A brief history:

1962: The idea of creating a governmental body to address healthcare concerns in Nigeria was first proposed.

1999: Military Head of State, Abdulsalam Abubakar enacted the National Health Insurance Scheme (NHIS) into law by decree on 10 May 1999.

2006: President Olusegun Obasanjo formally launched the agency and became the first registered NHIS member.

2012: The NHIS covered only about 3% of the population (5 million people).

2013: 98% of all Nigerian federal employees and 2 million additional private sector workers were signed up with NHIS.

2022: The NHIS was transformed into the National Health Insurance Authority (NHIA) with the signing of the National Health Insurance Authority Bill (2022) into law by President Muhammadu Buhari on 19 May 2022. The new law makes health insurance compulsory for all Nigerians and legal residents. It also introduced tighter measures to properly regulate state and private health insurance programs.



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