5 Reasons why enrollees are opting out of your HMO and how to solve them


Getting new enrollees to join your HMO is great, but getting them to continually renew their plan is where the real work begins. The HMO competitive landscape in Nigeria is getting more and more vicious day by day with enrollees constantly comparing what is on offer, and playing musical chairs with different HMO providers.

When enrollees choose to opt out of your HMO, it is usually because they are not quite satisfied with the service you are offering. We have interviewed several HR managers and curated the top 5 common reasons enrollees change their HMO provider. We also have some tips on how to solve them.


Reasons why enrollees are opting out of your HMO

1. Dissatisfaction with physician services.

Having to wait long hours to see doctors, specialists, and carry out tests is often the order of the day when people go to hospitals to pay out of pocket. However, when these people become HMO enrollees, there is a tendency for their expectation to rise and they are generally not as patient as they used to be before enrolling in an HMO. This is why if they are constantly kept waiting before they can be attended to, have to wait for weeks to get an appointment with a specialist, not being able to get medical services fast enough when they were ill, and not getting as much attention as other patients who pay out of pocket, they begin to rate your HMO less. Another way through dissatisfaction can set in is when the primary HMO doctors refuse the enrollees the services, they believe they need. For example, if an enrollee strongly believes they need to take an X-ray, see a gynecologist and the doctor thinks otherwise, the enrollee may easily conclude that they are simply trying to cut costs. The result? They lose interest in your HMO and opt-out as soon as they can.

The first thing you want to do to solve the waiting problem is to incorporate telemedicine into your HMO’s services. Telemedicine has proven to improve patient satisfaction. It would not only reduce the burden on the doctors, but it would also make accessing healthcare easier and more convenient for your enrollees. As it allows them to interact with their doctors in the comfort of their home, they would be more inclined to keep choosing your HMO over and over again. 

You can also solve this issue by routinely getting ratings and feedback from selected enrollees in all hospitals, clinics, and labs under your HMO. This way, you can assess their experiences, make necessary adjustments, and win them back on your team. 


2. Discovering that the HMO made false claims upon enrollment.

While trying to sign up more enrollees, there is often a tendency to make misleading and false claims that prospective enrollees would find hard to ignore. Misleading enrollees about the scope of your coverage plan, promising them quality healthcare and then going on to deny them needed services is akin to making false claims and also comes across as being fraudulent. 

An enrollee that comes on board simply because they were made to believe that hospice care is covered by the HMO or home health care would be made available on-demand would have no reservation about opting out as soon as they can. To eliminate this risk, stick to the facts while advertising your services and make sure to always give adequate and precise information to your prospective enrollees.


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3. Not being able to easily change the primary HMO doctor. 

The primary care physician an enrollee chooses is often the most important factor in determining if they would get satisfaction with your HMO or not. In cases when enrollees find out that their preferred doctor is not affiliated with your HMO, they have to start afresh and hope that the doctor they choose is one that they would feel comfortable with. If for any reason, they find that they do not like their doctor’s bedside manner or even his/her personality, they may decide to change. It may also be that they are moving and would want a hospital/doctor closer to their new location. It is only right for them to expect your HMO to make this happen as easily as possible. If they find the procedure of changing doctors/hospitals to be too tedious or the HMO isn’t being supportive of their decision, they might lose interest in the HMO altogether and simply enroll in a new one.

Keeping the changing procedure as straightforward as possible would help you to not lose enrollees. Also, let the enrollees know how long it takes for the change to be effective and make sure to carry them along on the progress of the procedure.


4. Making enquiries by telephone is too difficult.

The call center is a very important department of any HMO and it is best if it runs 24/7. An HMO with a subpar call center is likely to have lots of dissatisfied enrollees. For example, if the HMO’s call center only works a 7 a.m.-8 p.m. schedule, enrollees that experience an emergency and go to the hospital after 8 p.m. will have no one to make clarifications and enquiries from. In most cases of emergencies, patients do not the luxury of time to go to their regular hospital and see their primary HMO doctor. Hence, the healthcare providers in the random hospital or clinic they go to may need to make clarifications. As a result of this, they might not get the medical attention they need at the time. The HMO then comes across as being irresponsible and one that is only after enrollees to make money without being available when they are needed.

In addition to eliminating this risk by running a call center that is available round the clock, the HMO’s call center should be properly staffed so that it wouldn’t be just one or two persons burdened with calls from many enrollees.


5. High costs in relation to services covered

People always want to get value for money and when it comes to health-related issues, this becomes even more applicable. If enrollees perceive that the medical services that your HMO covers do not correspond with the amount of money they pay, they would be on the lookout for another HMO that offers more services at an equal or lesser price. When high cost in relation to coverage is combined with other aforementioned areas of dissatisfaction, no enrollee would hesitate to ditch your HMO for one that they deem better.

This does not necessarily mean that you should place huge cuts on your charges. You can, however, adjust your prices such that it is competitive. You can also introduce new services that would give your coverage list a boost as well as including complimentary services that would make your enrollees convinced that they are getting enough bang for their buck. 


Getting your enrollees on board is surely not the easiest thing. However, pushing them away might be easier than you can imagine. The reasons above are the top 5 likely causes that explain why there is an increasing list of enrollees that have opted out of your HMO. Put the practical solutions into practice and before long, there would be no such list.


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Post Comments:


  • Adeyanju Mercy May 20, 2022

    How can someone change HMO please

  • Charles Akinniyi September 5, 2020

    Great job on identifying some of the pain points faced by enrollees however, many clients leave due to lack to access to high end hospitals and this can sometimes be difficult to provide due to an insistence on paying low premiums.

    This for me is one of the major reasons why clients (enrolees) opt out.

    Thank you.

    • Health Connect 24×7 September 7, 2020

      Hello Charles,

      Thank you for your submission, it was very insightful.


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