HMO claims and scheme billing for Nigerian hospitals
Scheme revenue is rarely lost at the claim stage. It is lost earlier — an authorisation that was never recorded, a service delivered under the wrong tariff, or a bill closed before the shortfall was reconciled.
Key takeaways
- Capture eligibility and authorisation at registration, not at billing.
- Hold a tariff per payer so the charge is correct at the moment of service.
- Track each claim through submission, adjudication, payment and shortfall.
- Reconcile remittances line by line, not in aggregate.
- Report denial reasons back to the departments that cause them.
Where scheme revenue actually leaks
- Patient treated as scheme-covered without a recorded authorisation reference
- Service priced from the cash list instead of the payer tariff
- Investigation or drug delivered but never posted to the encounter
- Claim submitted without the supporting clinical documentation
- Part-payment received and the balance never pursued
- Denials counted but never traced to a cause or a department
The control points to put in place
- Eligibility and authorisation fields required before a scheme encounter opens
- Payer-specific tariffs and exclusions applied automatically to charges
- A claim record linked to the encounter, its orders and its documentation
- Status history for each claim with dates and the responsible user
- Remittance import or entry matched against submitted claim lines
- Ageing and denial-reason reporting for management review
What this looks like in MedFlow
MedFlow keeps insurance and revenue-cycle management in the same platform as the clinical record, so an order raised in a consultation carries its payer context through to the bill and the claim. Claim status, ageing and denial reasons are reportable, and every change is audited. The specific payers, tariffs and claim formats configured are set up per facility during implementation.
Questions to ask before you commit
- Can the system hold several payer tariffs and apply them by encounter?
- Is authorisation enforced or advisory at registration?
- Can a remittance be reconciled at line level and leave an auditable balance?
- What reporting exists for denials, ageing and per-payer performance?
MedFlow home — Contact Ubora One Limited