A Health Maintenance Organization (HMO) is an organization that provides health coverage for a monthly or annual fee.
The HMO is an organization that provides or arranges managed care for health insurance, self-funded health care benefit plans, individuals, and other entities, acting as a liaison with health care providers (hospitals, doctors, etc.) on a prepaid basis.
See Also: Process For HMO Registration In Nigeria
It is a group of medical insurance providers that limit coverage to medical aid provided from doctors that are under the contract of HMO. These contracts allow for premiums to be lower since the health providers have the advantage of having patients directed to them; but these contracts also add additional restrictions to HMO’s members.
Roles / Functions Of Health Maintenance Organization (HMO) In Nigeria
The following are the functions of the HMO in Nigeria
- They ensure that contributions that are made are kept in the scheme’s accredited banks.
- They ensure that processing of claims is done effectively.
- They also gather appropriate contributions and make necessary payments to the right pools in a timely way.
- They market in-line with the NHIS guidelines.
- To ensure that approval of referrals are done within the stipulated time and undertake the necessary follow up to complete the referrals.
- To market health plans to employers of several public and private sectors.
- To gather and submit the encounter data forms from healthcare facilities to NHIS.
- Getting in touch with health care facilities that are only accredited by the scheme with the aim of providing health care services.
- To follow all the other provisions as outlined in the operational guidelines
- Conducting functions which are stipulated in the NHIS operational guidelines.
- To deliver accounts to the National health insurance scheme as required in the operational guidelines.
- Delivering monthly returns to the scheme on capitation and fee-for service payment to secondary & tertiary healthcare facilities.
- Providing continuous sensitization and education of the enrollees.
- To create and ensure that there is a quality assurance system to provide quality healthcare by the health care facilities.
- Provide risk management enlightenment for enrollers and providers.
- They should also ensure that disease management guidelines are created so that providers can achieve both high quality and cost effective care.
- They should have primary and contracted providers in the regions that they cover.
- To collect contributions of employer and employees from different parts of the country.
- To register employer and employees
- To register service providers, after making sure that they meet the minimum NHIS standards.
- To give health promotion and education
- To create an effective quality assurance systems
- To ensure qualitative and cost effective healthcare services to contributors through the healthcare providers (HCPs).