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OMETE: Why insured patients may soon start paying upfront

Young doctor filling insurance form. PHOTO | FOTSEARCH
Young doctor filling insurance form. PHOTO | FOTSEARCH  

In a move that could have serious ramifications to patients if fully implemented, doctors are mulling deliberations to split the payment modalities of patients’ bills.

Under the proposals, consultation fee, a mandatory component of most medical visits to private practitioners’ offices and clinics, would be footed up front by the patients who will then seek reimbursement from their insurers.

The suggestion arises as a result of persistent delays in the settlement of claims to most doctors offering services to insured clients.

This problem is highlighted by the findings of a survey among private wing consultants’ clinics at Kenyatta National Hospital and Upper Hill in Nairobi where most of the city’s specialists are based.

As third party contractors in the current arrangement, insurers seem to be bullying medical service providers.

The model would pit patients directly against their insurers offering them greater autonomy in evaluating the insurers’ performance and decisions on whether to renew their policies with one or change to another.

Delays in payments in healthcare are, however, replicated in other sectors of the economy such as the retail supermarket chains, highlighting a growing malady affecting suppliers and service providers.

What is disturbing though is the fact that this is a sector where most premiums are paid upfront. In their defence, most insurers attribute the delays to internal processing constraints in claims settlement. However, a more convincing explanation is needed.

Claims settlement is becoming a key choice criterion for those purchasing premiums both for medical and other classes of insurance.

Current payment time lines stated vary between 30 to 60 days, but most if not all insurers are not meeting this, driving the movement towards this new policy.

Initial findings of the ongoing survey amongst health services providers show the average time lines are two or three months late.

This scenario may be contributing to the rising cost of services as doctors increase their fees to cater for this.

The industry regulator, Insurance Regulatory Authority (IRA), has not been putting oversight supervision on this matter.

Guidelines on penalties to such insurers and claimants and complaints channels are not easy.

Small insurers in particular struggle to settle, but even large insurers too, case in point being the teachers’ scheme previously under Bliss GVS and its current operator AON.

Given the premiums involved in this case, it suggests that perhaps the amount of premiums collected is not an important determinant of payments times.

It is no coincidence that the top overall insurer also has one of the best claims settlement times as was recently highlighted in the media.

This positive fact seems to bolster their clientele base’s assurance in their services.

The IRA should impose supervision guidelines to address doctors’ and patients’ concerns.

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