Fraud has been increasingly prevalent in the medical class of business. FILE PHOTO | NMG
Insurance fraud has been known to affect the entire insurance
value chain and is now one of the top growing concerns amongst insurers
in Kenya.
Although fraud affects all business lines in
the insurance sector, it has been increasingly prevalent in the medical
class of business and it has been perpetrated in various ways.
Collusion
between the policy holders and health service providers, inflated bills
from hospitals and clinics, hospitals making patients take unnecessary
tests, impersonation or dual membership by policy holders and pharmacy
related fraud cases are some of the ways the perpetrators are executing
fraudulent activities in the industry.
Some health
service providers have been known to apply two tier pricing for their
services. This usually happens when a patient who presents their medical
card is charged more than a patient who pays in cash for the same
service.
The effect of this has been the exhaustion of medical cover
benefits before the duration, leaving the insured customer exposed for
the remaining period of cover.
In some cases, patients
are subjected to unnecessary tests that have nothing to do with the
treatment of what they are ailing from so that the health provider can
bill the insurer.
The unsuspecting patient undergoes a
number of tests and since the patient trusts the doctor, and they don’t
have to pay out of pocket, they comply without questioning.
Patients
who pay for cash are usually more alert and often ask why the tests
need to be done. And in such cases, you find some doctors will order
only the specific test.
We also have fraud committed by the insured who allows another individual to access medical services using their credentials.
They
collude with the doctor and permit someone else other than the insured
to use their medical card in the health facility and for billing at a
pharmacy for someone else’s prescription.
Identity
theft is also becoming common where the health facility uses the
identity of an insured patient and bills for services that were not
rendered to them using that patient’s information.
What then is the way forward? At Jubilee Insurance
we continue to strengthen and tighten our operations by automating our
processes and systems that link a specific patient to the claim they
have made.
Technology
will enable us to monitor and track where services were rendered, how
long it took, what was the cost amongst other details and this will make
it harder for fraudsters to falsify claims.
We will
also monitor the quality of service our customers receive where we have a
360 degree view of the entire process, from when you arrive at the
health facility and run your medical card, and the subsequent processes.
This will enable us to give feedback to our providers
on their processes to ensure our customers enjoy efficient and seamless
services whenever they visit these facilities.
Whether
you are covered under a corporate insurance scheme or an individual
insurance policy, fraud eventually translates into higher costs, either
in premiums at renewal and/or you end up paying for your bills when you
exhaust your cover before time.
Our goal is to increase
insurance penetration in Kenya from the current 2.7 per cent by making
insurance services more affordable and accessible to Kenyans.
Patrick Tumbo is CEO, Jubilee Insurance, Kenya.
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