A tamper-proof membership information and administration management system for medical schemes will be launched in East Africa next year. The smart card technology is expected to help curb the rising incidence of fraud in the region’s health management sector. The technology, developed by Health Data Systems Ltd, a Nairobi-based firm set up in February, will provide accuracy in member identification.

"The current system where photos, ID cards, diskettes and paper cards are used to identify beneficiaries of medical cover is not working well in the market," said the executive director and founder of Health Data Systems Ltd, Isaiah Okoth. "By using smart card, the time taken to process information about a patient will be substantially reduced as will be, fraudulent claims. We expect the credit period to come down from the three months to about two weeks at most."

According to Mr Okoth, the card, which is the size of an ATM card, provides secure member’s information, making the administration of healthcare provision more accurate, quick and affordable. "Smart cards allow patients to carry their updated ‘medical files’ with them at all times," said Mr Okoth. 

The firm is in the process of setting up the infrastructure and conducting field tests in readiness for the launch in Nairobi in January and in Uganda and Tanzania by June. 

"We believe there is a market out there for smart cards in health management," said Mr Okoth. "In Kenya alone, there are about 15,000 healthcare facilities – private and public hospitals, clinics, health centres and pharmacies – but it is the corporates, medical schemes, insurance companies and health management organisations (HMOs) that will find the card ideal to their purposes." 

In the first phase of the planned rollout, Health Data Systems will target 1,000 healthcare providers in Kenya. The facility comes at a time of uncertainty amid jitters in Kenya’s health management sector, triggered by the collapse of some major players in the industry amid a rising incidence of fraud.

Currently, there are about 25 HMOs in Kenya, half of which are facing serious liquidity problems, with the majority having had to downsize their staff to remain afloat. 

The industry estimates that up to 30 per cent of claims are currently fraudulent. Mediplus, the most recent of the HMO failures, went under early this year with close to Ksh20 million ($256,400) owed to hospitals. 

Sources say that major hospitals in Nairobi, including Aga Khan Hospital, MP Shah, The Mater and Avenue Hospital, are currently not accepting patients covered by Health Plan Services, Medex Marketing Services and Mesco Consultants Ltd. 

Most of the HMOs are reducing their staff in large numbers as a result of the crisis. The common types of fraud include billing for medicines not prescribed or given to patients and billing for tests not done or not relevant to diagnosis. 

According to the chief executive of Health Plan Services Ltd, Dr Richard Ayah, whose firm is restructuring as a result of the current hard times, the crisis afflicting the sector is due to the panic that followed the collapse of Mediplus early this year.

"The effect has been similar to a run on the banks, with major providers cancelling credit facilities or imposing harsh, punitive and unsustainable conditions to operate credit accounts," said Dr Ayah.

He said that bills from major hospitals had risen two-and-a-half times since April. "For example, where we were paying a hospital Ksh1 million (US$12,820) a month, the bill went up to Ksh2.5 million (US$32,050). There are rising cases of inflated bills by doctors who bill one procedure in three different ways," he added.

At the heart of the smart card concept is the use of dedicated and secure information network technologies to link patients, healthcare providers and relevant medical schemes. According to Mr Okoth, the infrastructure has been defined and structured to ensure that all participants can access and update members’ medical information twice a day.

Upon visiting a medical facility, the card holder will be identified by inserting their card into a smart card reader, which will in turn ask for a PIN number or biometric identification. After accepting the PIN, the attending medical professional will be able to access the patient’s basic medical information (including cover limits) and administer treatment.

Once the treatment has been administered, the healthcare provider will be required to provide basic details of the service administered before being allowed to deduct the relevant charges from the card. 

The updated information is then stored on the smart card and transmitted immediately to the relevant medical scheme for processing via a dedicated healthcare information network. In an emergency situation, a doctor will be able to access patient information by verifying information from the patient. 

The Nation