Dr Patrick Korie, the Managing Director SUNU Health, a national Health Maintenance Organisation (HMO), has appealed to health care providers to desist from self referral.
Korie made the appeal in an interview with the News Agency of Nigeria (NAN) in Lagos on Thursday.
The MD said that some providers that attend to secondary and primary care now do self referral.
According to him, a situation whereby a provider carries out a service without notification to the HMO is doubtful.
“The treatment of client in medicine is based on primary, secondary and tertiary care.
“Primary care is taking care of capitation which the HMO must continue to pay while the Secondary care is complex medical conditions that are handled by professionals and require referrals.
“For a provider to refer any client, you have to carry the HMO along, obtain a code and get paid.
“We need accountability; there should be accountability in whatever we are doing and SUNU Health insists that the right thing must be done,’’ he said.
Korie said that there was agreement between the HMOs and hospitals.
“You have process on what to be done; you have agreement on when to pay if a provider renders a service and submits claim for a provider to be paid.
“Anybody that defaults is in error. Some claims are submitted but not according to the process and procedure,’’ he said.
He said that a provider had up to 72 hours to obtain a code for treatment if it was an emergency case and an HMO had up to 24 hours to respond to such situations.
According to him, if it exceeds 72 hours, then protocol has been breached.
The MD said that SUNU Health saw it as a responsibility to pay all genuine claims.
He said that to a certain extent, cancer and some chronic diseases are covered by National Health Insurance Scheme (NHIS), depending on the clients benefit package.
He also called for a review of NHIS fees based on laid down rules. (NAN)