The National Health Insurance Authority (NHIA) sanctioned 96 healthcare entities in 2024, including 49 healthcare facilities and 47 health maintenance organizations (HMOs), for various service delivery breaches under the national and State health insurance schemes, it has emerged.

Based on the findings from the investigations, the NHIA issued 84 formal warnings to healthcare facilities and facilitated the refund of ₦4,375,500 to 54 enrollees by 39 facilities, it revealed, adding that four facilities were suspended and six were delisted.

Among the HMOs, 35 received warning letters with directives to implement corrective measures, while 12 were compelled to refund ₦748,200 to 15 enrollees.

The action followed investigations into thousands of complaints lodged by enrollees and was taken per the NHIA’s operational guidelines and the NHIA Act 17 of 2022, the agency’s Acting Director of Media and Public Relations, Emmanuel Ononokpono, said in a statement on Sunday.

According to him, the sanctions ranged from formal warnings and enrollee refunds to suspensions and the delisting of non-compliant providers.

He further explained that the enforcement measures are part of its renewed focus on ensuring quality care and accountability in Nigeria’s health insurance ecosystem.

According to him, the agency’s 2024 Annual Complaints Report, compiled by the Enforcement Department under Acting Director Dr. Abdulhamid Habib Abdullahi, revealed that a total of 3,507 complaints were received during the year.

The report also showed that, of these 2,929 cases, approximately 84 percent were fully resolved.

The breakdown showed that 2,273 complaints were filed against healthcare facilities, while 1,232 were directed at HMOs.

Only two complaints were lodged against enrollees, the report also showed.

The agency also revealed that the most common issues raised against healthcare facilities included the unavailability of essential medicines, denial of entitled services, out-of-pocket payments for services covered under the scheme, and non-disclosure of payment details.

For HMOs, it said, complaints focused on delays or outright denials of referral authorisation codes, prolonged settlement of reconciled claims, and failure to monitor the quality of care provided by their affiliated facilities.

The report also highlighted that all complaints requiring investigation were addressed within the standard timeframe of 10 to 25 days, with an average resolution time of 15 days.

The agency also stressed that in cases where delays occurred, complainants were informed of the reasons and the ongoing resolution efforts.

Complaints reached the NHIA through various channels, including in-person visits, official letters, emails, phone calls, and the NHIA call centre.

To further streamline the complaint resolution process, the NHIA introduced a new policy mandating that referral authorization codes must be issued by HMOs within one hour.

Should an HMO fail to respond within this window, healthcare providers are authorised to proceed with treatment, in line with an established emergency protocol.

Commenting on the development, NHIA Director General Dr. Kelechi Ohiri described the sanctions not as punitive but as part of broader efforts to enforce accountability, raise service standards, and rebuild public trust in the health insurance system.

Noting that the efforts are crucial to driving enrollment and improving the patient experience, the Executive Secretary said, “Enrollees deserve the best care, and we are committed to ensuring that happens.

“These sanctions send a clear message that substandard care will not be tolerated. At the same time, we commend providers who continue to deliver excellent services”.

He added that with the recent adjustment of capitation and fee-for-service payments marking the first such revision in twelve years, healthcare providers now have greater capacity to offer quality, timely services.

Ohiri reaffirmed that NHIA’s complaint and grievance management process reflects its commitment to transparency, continuous service improvement, and equity in healthcare delivery.

These efforts, he noted, are in line with President Bola Ahmed Tinubu’s agenda to achieve Universal Health Coverage (UHC) for all Nigerians.