To recover unpaid claims from health insurers, HMOs and mutual health schemes, a facility must act at three points: before treatment by checking cover, at billing by submitting a complete claim, and after submission by tracking each claim until it is paid. Delays often stem from incomplete claims or irregular follow-up, two causes the facility can fix itself.
Key takeaways
- A claim is secured before treatment: the patient’s eligibility and pre-authorisation are checked at reception.
- A complete claim file (authorisation, services, supporting documents) limits rejections.
- A receivables report by payer and by age, updated weekly, shows where to act.
- Follow-ups run on a fixed schedule and every exchange is recorded.
- A monthly review of rejection reasons fixes practices at the source.
Why claims on insurers and HMOs pile up
In a private clinic, part of the revenue depends on insurers, HMOs, mutual health schemes and employers who cover their staff. When these payments are late, cash flow tightens: salaries, drug suppliers, maintenance.
In Nigeria, many insured patients are covered through health maintenance organisations (HMOs), under National Health Insurance Authority (NHIA) programmes or private plans. In Ghana, facilities accredited under the National Health Insurance Scheme (NHIS) submit their claims to the National Health Insurance Authority. In both settings, the same causes keep coming back.
- Eligibility not checked at reception: expired card, limit reached, service not covered.
- Missing pre-authorisation for an admission or an expensive test.
- Incomplete claim: missing signature, missing prescription, wrongly described service.
- Claims submitted late, bundled at the end of the quarter.
- No tracking: nobody knows which claims are paid, rejected or pending.
Example: while preparing its annual accounts, a 40-bed clinic in Port Harcourt finds HMO claims that had not been followed up for months. Some had been rejected for a missing document, but the rejection letter sat in a drawer because no one was in charge of it.
Step 1: secure cover at reception
Recovery starts before treatment. At reception, staff check the patient’s identity, the validity of the card or enrolment details and the level of cover.
- Check the card or enrolment details: name, member number, expiry date.
- Check the payer’s conditions: covered services, limits, co-payment.
- Request pre-authorisation where required, before a planned admission, and keep the written answer. With an HMO, this often takes the form of an authorisation code.
- Tell the patient what remains payable.
Example: for a planned procedure, a clinic in Ibadan obtains the HMO’s authorisation several days ahead. The patient knows her share, and the claim goes out with the authorisation attached. These checks are detailed in our article on third-party payment and health insurance.
Step 2: build a complete claim file
Each payer has its own requirements, but a complete file usually contains the same documents. Draw up a checklist per payer and have a second person check it before submission.
| Document | Purpose | Check |
|---|---|---|
| Itemised invoice | Lists services, quantities and amounts | Descriptions and tariffs match the agreement |
| Pre-authorisation | Proves approval | Dated before treatment, amount respected |
| Copy of card or enrolment details | Proves eligibility | Valid on the date of care |
| Prescription | Justifies drugs and tests | Signed by the prescriber |
| Discharge summary | Justifies the admission | Dates consistent with the invoice |
Example: a medical centre in Cape Coast sets up a cross-check before submitting NHIS claims: the billing officer prepares the file, the administrative manager ticks the checklist. The aim is simple: no claim leaves with a missing document.
Step 3: track receivables by age
Tracking relies on a simple table: for each payer, the amount billed, paid, rejected and pending, in naira or cedis, sorted by age. It is updated weekly and presented monthly at the management meeting.
| Claim status | Action | Owner |
|---|---|---|
| Within the agreed payment period | Check the acknowledgement of receipt | Billing |
| Payment period exceeded | Written reminder with the list of claims | Billing |
| No response to the reminder | Phone call and meeting with the payer’s officer | Administrative manager |
| Still unpaid after the meeting | Letter from management, review of the agreement | Management |
Example: if an HMO agreement provides for payment within 45 days, the reminder goes out the day after the due date, not at the end of the quarter. Average payment time and rejection rate per payer are among the key indicators of a hospital dashboard.
Step 4: follow up with method and handle rejections
An effective reminder is precise: claim numbers, amounts, submission dates, copy of the acknowledgement. Every exchange is logged with the date, the contact person and the commitment made. Example: the note “March claims promised before the 15th” allows a targeted reminder on the 16th.
Turn rejections into corrective actions
Every rejection has a reason. Group them monthly: expired card, missing authorisation, service not covered, tariff error. Example: if several rejections involve expired cards, the fix happens at reception, not in the billing office.
Rely on the agreement
The agreement signed with each payer sets tariffs, payment periods and dispute procedures. Reread it before any negotiation. Example: a facility that knows how long it has to contest a rejection handles rejection letters as soon as they arrive, instead of letting that period run out.
Claims recovery and MediFlow
MediFlow’s billing module, in development, brings together services, insurance and the cash desk: claims owed by insurers and health mutuals will be tracked in the same tool.
Follow-up and receivables tracking as described here remain a team discipline, to put in place right now.
Frequently asked questions
How soon should we follow up with an insurer or HMO?
The starting point is the payment period set in the agreement. Send a written reminder as soon as that period is exceeded, then call if nothing happens. Without a clear agreement, set an internal schedule and apply it to every payer.
How can we reduce claims rejected by insurers?
Check eligibility and pre-authorisation at reception, then check each file against a document checklist before submission. Review rejection reasons every month to fix the cause at the source. Rejections for an expired card or a missing document are avoidable.
Who should be responsible for claims recovery in a clinic?
Appoint one person to own the follow-up, often in the billing office, with a management contact for older claims. This person keeps the receivables report up to date and presents the situation every month. Without a named owner, follow-ups eventually stop.
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