The Curious Habits of Insured Individuals

With various models of payments for health services, the world over in general and Kenyans in particular, people are always seeking ways to beat the systems for maximum advantage. This queer behavior has infiltrated the health industry. Unfortunately, the enrolled members who are players in this unfortunate game have not understood the adverse effect of their actions, on themselves and on the entire health service delivery cycle.

Some patients will move from one facility to another to get treatment for the same condition to get the same drugs; the intention is to sell the drugs for a few bucks, without realizing that they are depleting their own cover amounts. When they have a medical need, they realise they do not have enough balance and unfortunately, they already used the money they got from the illegal transaction for other purposes.

Consider a scenario where a patient knows that they have unlimited access to their medical cover. There are those who will unnecessarily go to their service provider with all manner of health complaints, not because they are unwell but they do so saying it is their money which they must utilize to capacity. They declare doctors incompetent when they are told there is nothing clinically wrong and even when some tests are done nothing is seen, to look genuine. Others, knowing their cover allows them to go to higher-level facilities will opt for such facilities even for what could have been taken care of at lower levels - such as level 2 and 3 to feel they belong, not knowing it depletes their account.

Another type of fraudulent activity to access services is identity theft. Generally, in Kenyan cultures, people are named after specific individuals and they carry the same names along bloodlines. This means it is very easy to find people who share the same names, some in the same age group and others in different age groups. Where there are no biometrics and other more stringent verifications, people share their cards to access services.

Talking about these weird tendencies Jayesh Saini, CEO, of Bliss Healthcaresaid that some of this behavior has led the insurers to put a co-pay amount for every trip to some facilities. The co-pay has to some great extent helped curb abuse of medical schemes, for both privately and publicly insured persons. He said that this has also buffered the insurers from losses that are attributed to this kind of medical fraud.

Jayesh Saini says there is a need for insurers to educate the public on various critical aspects of the medical insurance schemes so that they can better manage their accounts with understanding. He also advocates that at a bare minimum, all insurers should ensure biometrics are used noting that no two people share this kind of data.