Getting paid by HMOs and NHIA without the paper chase
By Fikacare team 5 min read
Claims are often the largest recoverable revenue in a hospital and the easiest to lose. Here is how Fikacare is designed to capture the encounter at reception, generate the claim from the visit, and track it to the last kobo.
In many Nigerian hospitals the HMO desk is a filing cabinet, a spreadsheet and one person's memory. A patient on a scheme is treated, the encounter form is filled in by hand, the claim is typed into a document at the end of the month, printed, sent, and then waited for. When the remittance arrives it is less than the claim, the difference is not explained, and the shortfall is absorbed because chasing it would take longer than it is worth.
This is often the largest recoverable revenue in the hospital, and it is lost not in one place but in a dozen small ones: encounters never claimed, claims sent late, rejections never resubmitted, part-payments never followed up, and capitation income that nobody reconciles against the roster.
A note on where this sits in the product
Fikacare is being built in phases, and each phase is proved in a working hospital before the next begins. Recording a patient's scheme and enrollee number at reception, charging at the scheme's tariff and posting the receivable belong to the clinical and revenue spine, which comes first. The full claims cycle, from batching through submission, remittance, ageing and capitation, is a later phase built on top of that spine. We would rather say so plainly than promise a date. What follows is what the system is designed to do when that phase is complete.
Start at reception, not at month end
A claim is only as good as the encounter it describes, and the encounter is captured at the front desk. Each HMO scheme is set up centrally with its tariff schedule, covered services, exclusions, authorisation rules, submission format, claims-desk contact and payment terms. When a patient arrives, their scheme and enrollee number are recorded on the visit, and the desk is warned if the enrollee's eligibility has expired.
Where a scheme requires pre-authorisation, the request and its reference are captured on the visit before the service, not reconstructed afterwards from memory.
The claim writes itself from the visit
Charges in Fikacare are raised automatically from clinical events: a consultation, a laboratory order, a dispensing, a procedure, a bed-day. For a scheme patient those charges are priced at the scheme's tariff, and the price is stored on the charge at the moment it is raised, so a later tariff change never rewrites history.
The claim is then generated from the visit: the diagnosis coded in ICD-10, the itemised services at the scheme's tariff, and the encounter form printed in that scheme's own format. Nobody re-keys anything. If a service was delivered and charged, it is on the claim.
Claims are batched by scheme and by period, producing the invoice and cover letter ready to send, and exported to the spreadsheet layout and PDF the scheme asks for. The layout for each scheme is kept as a template the HMO desk can adjust, because schemes change their forms and the hospital should not have to wait for us.
Tracking what happens next
Sending the claim is the beginning, not the end. Each batch is tracked through submission. When remittance arrives it is captured against the claim, and a part-payment or a rejection is recorded with the scheme's reason code. A rejected line goes into a resubmission workflow rather than a drawer.
The receivable is posted to the ledger when the claim is raised and settled when the remittance is received. Any shortfall between the two is written off explicitly, with a reason, and reported. It is never silently absorbed. The owner can see, for every scheme, how much was claimed, how much was paid, and how much was given up and why.
Ageing by scheme
The single report that changes behaviour is the ageing report. For each scheme it shows what is outstanding and for how long, so an unpaid claim becomes a debt to be chased rather than a figure that quietly drops off a spreadsheet. It is the same idea as the receipt continuity report on the cash side: the exception is raised now, while it can still be acted on.
Capitation kept separately
NHIA capitation is a different kind of income and is tracked as such: a per-enrollee monthly payment against a roster of enrollees for that month, with income posted when it is received. It is never mixed with fee-for-service claims, so the two can be reconciled independently and a shortfall in either is visible on its own.
What a reconciled cycle looks like
The test we have set for this part of the product is a plain one: one full claim cycle submitted, tracked and reconciled entirely within the system, with no side spreadsheet. Every claim traceable to its visit, every remittance matched to its claim, every shortfall explained, and the ledger agreeing with the scheme's statement.
That is what the paper chase is replaced with. Not a form that is filled in faster, but a record that was already complete when the patient left the building, and a report every morning that says who owes the hospital what.