Exploitive Hospitals Using Privately Insured Patients as Cash Cows

By Virginia Mwangi

Fraud has, often, been reported in hospitals using privately insured patients as their cash cows. This form of theft has become the latest money-making scheme mostly targeting patients covered by private health insurance.

Medical insurance management firms, especially those with a regional presence, continue to post losses as a result of the high incidences of fraud.

Kenya’s Insurance Regulatory Authority (IRA) shows that the sector posted a loss ratio of 76 percent in the third quarter of 2016 across the 18 insurance companies offering medical covers. This can only mean that they paid more claims than the premiums they had received.

Patients covered by private health insurance companies are largely exposed to fraud and are habitually double charged on services especially consultation which mostly goes unnoticed by the patient.  These patients have prescribed medication than they barely need, are put on hospital admission that is not always necessary and is overcharged for the services as well.

A good case scenario is Pauline, an employee of a well-established private company, who had taken her 3-year old daughter to Gertrude’s children hospital in Pangani. The young girl had a discharge from one of her eyes. Pauline was prescribed an eye drop for the child’s eye but while at the hospital the child constipated and the good doctor felt concerned causing her to refer them to the hospital’s Muthaiga branch. Pauline’s daughter was to undergo an abdominal scan.

Pauline proceeded to Muthaiga where she was charged for consultation, 1950 shillings, despite having been charged at Pangani. While at the waiting bay, another parent was already complaining of a consultation fee double charge which was quickly resolved as the parent demanded. Pauline, a soft-spoken lady, noticed a similar issue on her charge form and upon raising concern, the accountant casually told her nothing could be done at that point. Sadly, another patient had been used to milk the insurance company.

Most patients are also not aware that there are generic and branded drugs; they are not able to read the prescription either, most pharmacists, therefore, end up selling them generic drugs at the cost of branded drugs. Generics happen to be cheaper than branded drugs.

Whose responsibility is it to monitor the huge sums of money released to health insurance companies, is it the company that pays the patient, the patient that pays the premiums or the hospital that is paid by the insurance? It is probably the right time that the person supposed to play the role is clearly defined to save insurance firms from recording losses yearly.