Background: Medical audit systems are crucial to quality improvement in patient care and systems efficiency. But many countries struggle with the complexities of establishing or strengthening their audit systems. The JLN initiated the Medical Audits learning collaborative, leveraging South Korea’s advances in the area as a resource for building capacity and knowledge of other JLN member countries. Korea, a new JLN member, hosted three learning exchanges through 2016 (phases 1, 2 and 3), which have allowed countries to learn from each other and receive first-hand exposure to the established medical audits system in South Korea.
The JLN’s Medical Audits learning collaborative has been particularly relevant to Nigeria, as a country looking to improve its medical audits system. Country health system practitioners observed that there were prevailing gaps in understanding how an effective medical audit system functions. Through the joint learning, country members became more aware of critical components of an efficient system, such as the importance of peer review, gaps in management, policy implications, rules, triggers and fraud detection.
The knowledge and experience acquired so far has made an impact on both Nigeria’s systems and stakeholders.
Transfer of global JLN knowledge to country stakeholders
The experience and improved knowledge and capacity gained through the Medical Audit learning exchanges in South Korea have allowed us to hold an in-country training session for our many stakeholders. The training, held March 28, 2017, in Awka, Anambra State, was anchored by Integrated Health Care Limited – an accredited Health Maintenance Organization that is part of the NHIS.
The in-country training provided step-down capacity building to relevant stakeholders in Nigeria. Drawing from the global learnings, the session focused on:
- reviewing of proper claims and medical audits systems within the health insurance industry; and
- examining different components of an efficient medical audits system, such as rules, indicators, policy-related issues, outcomes and usages.
The training concluded with the following action items to work on:
- A plan to improve standards of efficiency, development of internal triggers and rules for seamless processes in operations;
- A systematic review of present systems and processes, and future plans that put to use tacit knowledge received and shared through the JLN collaborative; and
- Development of guidelines based on learnings from the Medical Audits collaborative.
Moving toward IT-driven medical audits systems
Nigeria is looking to Korea’s Health Insurance Review and Assessment (HIRA) system as a guide to drive efficiency in its NHIS.
The country is attempting to develop legal and policy level support to re-establish NHIS with a better IT system with improved linkages to the processes involved in claims review and payment. The management of NHIS is working on a robust IT system that will incorporate the business rules and enhance medical audit systems.
Nigeria’s National Health Act 2014, enacted to implement policy reforms needed for universal health coverage (UHC), makes provisions for a standard committee constituting members of the Ministry of Health and other stakeholders. Even though a medical audit system as envisaged is not part of the law at present, the knowledge gathered from the Medical Audits collaborative will bolster its implementation. Currently, the majority of claims are manual in nature. Even as the country does not have adequate resources for a complete IT reform, as in the case of the Korea, Nigeria is gradually beginning the reform towards e-claims. There are plans to establish a kind of systemic efficiency that cuts costs, enhances quality and reaps better value for money.
Collaborating with Korea on IT systems
Nigeria’s health insurance system is different from that of South Korea, the latter being heavily IT driven. However, learning from such an advanced system is helping Nigeria leverage lessons to tap their strengths and avoid mistakes during the developmental stages. Following the exposure to the growth and experience of Korea’s HIRA system, Nigeria’s chief executive officer of NHIS, Professor Usman Yusuf reached out to the commissioner of HIRA International Group, John Ryu for further discussions and potential technical support.
A high-level team visit from Nigeria to Korea is on the cards to further develop the collaboration around IT for medical audits.
The key success factors for JLN’s Medical Audits collaborative
Participating in the Medical Audits collaborative has been a great experience for Nigeria, particularly in the light of the following factors:
- The right mix of participants. The spectrum of professionals participating brought in day-to-day experience to aptly identify gaps in their operations. The learning exchange group maintains active knowledge sharing and has proven to be a good repository of capacity and grounded experience in the field of medical audits within their respective countries.
- South Korea as the mentor country. HIRA’s teams were able to practically demonstrate the process of implementing reforms, providing the participating countries with the needed pragmatic knowledge on medical audits.
- Countries’ access to Joint Learning Fund. JLN maintains a pool of funds to support countries that may not ordinarily invest their resources in learning. The Joint Learning Fund aids countries with capacity building and peer-to-peer learning.
The benefits of knowledge exchange
Active knowledge exchange accelerates movement within countries. Without the Joint Learning Network and the activities of the Joint Learning Fund, each country would work in isolation from each other.
Nigeria’s National Health Insurance Scheme and the Federal Ministry of Health remain grateful to the Joint Learning Network and the opportunity the Medical Audit collaborative has provided to learn and innovate improvements in our health systems.