When Madeline Mujawase took her younger son to a personal hospital in Kigali with what gave the impression to be a light fever and flu, she anticipated a routine session, therapy and a fast return dwelling.
As an alternative, what started with a nebulisation session within the emergency unit was a four-day hospital keep, a number of exams and mounting medical payments.
“I took my son to hospital with a light fever and flu. They carried out nebulisation on the emergency unit and he was bettering. Later, the physician stated we wanted to confess him to observe his fever,” Mujawase recalled.
“As a mum or dad, my first intuition was to not query the physician's choice, so I agreed.”
She anticipated to return dwelling the next day. As an alternative, the admission dragged on.
“The physician didn’t present up the entire day. My youngster remained beneath statement and solely got here through the night shift. When he arrived, he stated there was yet one more check to test for sinusitis.”
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The hospital keep stretched into a number of days, and discussions finally turned to surgical procedure.
“At that time, I turned uncomfortable with how a case that was imagined to be easy had escalated. Earlier than we knew it, we had spent 4 days in hospital.”
Past disrupting her household's routine and inflicting missed work, the expertise led to a dispute over the hospital invoice after her insurer questioned a number of expenses.
Mujawase stated the insurer challenged the need of some procedures and declined to cowl a part of the invoice, leaving her caught in a chronic dispute with each the hospital and the insurance coverage firm.
“The forwards and backwards was exhausting. You might be already apprehensive about your youngster, then you are attempting to grasp why sure procedures are being questioned or not lined.”
Her expertise displays rising issues amongst sufferers, insurers and healthcare stakeholders over whether or not pointless admissions, extended hospital stays, extreme testing and questionable prescribing practices are contributing to rising healthcare prices.
When therapy turns into costly
Medical specialists warning that extended admissions and intensive investigations aren’t all the time pointless. Some circumstances require shut statement, extra exams and specialist care earlier than an correct prognosis might be made.
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Nevertheless, issues come up when interventions will not be clinically justified. Sufferers typically lack the medical data to query healthcare professionals and due to this fact belief that each admission, check or prescription is important.
Business gamers say this imbalance can go away sufferers weak to avoidable prices.
The results lengthen past the rapid invoice. Medical bills are deducted from sufferers' insurance coverage advantages, which means protection could also be exhausted by therapy later deemed extreme, forcing households to pay out of pocket when extra severe well being wants come up.
A mum or dad whose daughter was handled at a clinic in Kimironko, and who requested anonymity due to the sensitivity of the problem, shared an identical expertise.
His daughter suffered what gave the impression to be a minor sprain throughout a basketball recreation. What started as a easy damage advanced into extended follow-up care, together with physiotherapy classes that continued even after she had totally recovered and returned to sport.
“It was perplexing. The additional prices, together with the 15 per cent affected person contribution and transport, saved including up. But, from our perspective, she had already recovered and was again on the courtroom.”
Why claims are disputed
Based on Emmanuel Sabayesu, Performing Govt Secretary of the Rwanda Well being Insurers Affiliation (RHIA), disputes between healthcare suppliers and insurers generally come up from coding and documentation errors, insufficient medical data, prior authorisation challenges, affected person eligibility points and handbook data-entry errors.
He famous that insurers function beneath completely different contractual preparations with suppliers, leading to various declare necessities.
Sabayesu stated wider adoption of paperless methods and digital workflows might enhance effectivity, cut back administrative burdens and minimise processing errors.
Whereas insurers say many disputes stem from administrative points, additionally they preserve evaluate mechanisms to confirm that billed providers had been truly offered and medically justified.
Healthcare suppliers, nevertheless, argue that the claims course of has develop into more and more advanced.
A consultant of a personal well being facility, talking anonymously, stated hospitals should navigate a number of approval procedures, intensive documentation necessities and incessantly altering insurance coverage guidelines.
Claims endure a number of verification levels, together with eligibility checks, pre-authorisation for specialised providers and insurer evaluations. Rejections typically stem from lacking documentation, discrepancies between supplier and insurer data, or evolving digital claims methods.
Digitisation bettering claims processing
The Rwanda Social Safety Board (RSSB), which manages claims beneath the Rwanda Medical Insurance coverage Scheme (RAMA), says reimbursements are guided by authorised tariffs, ministerial directions and contractual agreements.
A revised nationwide tariff authorised by the Ministry of Well being took impact in July 2025, adopted by amendments in February 2026.
RSSB says claims from personal well being services and pharmacies at the moment are submitted, verified and reconciled electronically via the Built-in Well being Billing System (IHBS), generally referred to as Kwivuza.
Public well being services are nonetheless transitioning from paper-based processes, however RSSB says it’s working with the Ministry of Well being in the direction of a completely digital system built-in throughout the well being sector.
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Claims are verified towards profit packages, authorised tariffs and contractual necessities earlier than reimbursement. The place discrepancies come up, suppliers are allowed to evaluate findings, submit supporting paperwork and make clear disputed providers.
If disagreements persist, they’re escalated via inside evaluate constructions and, the place crucial, referred to the Ministry of Well being for mediation.
RSSB says digitisation has considerably improved effectivity, decreasing pharmacy claims processing from greater than 90 days in 2020 to fewer than 15 days immediately. Related positive factors are anticipated as extra personal well being services are totally onboarded.
Docs urged to prioritise medical judgement
Brig Gen Dr Eugene Ngoga, Commandant of Rwanda Navy Instructing Hospital, stated sound medical judgement ought to all the time information affected person care.
Docs, he stated, ought to first take an in depth medical historical past and conduct an intensive examination earlier than ordering investigations.
“Investigations are there to assist prognosis, however they shouldn't be abused.”
He warned towards relying excessively on diagnostic exams with out first establishing a transparent medical foundation.
“There's no cause for having so many exams once we don't have any clue that this could be the issue.”
Fashionable diagnostic instruments, he stated, ought to affirm or rule out doubtless diagnoses—not substitute medical evaluation.
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Docs are educated to determine the almost certainly causes of sickness and order focused investigations accordingly.
For instance, a affected person with signs strongly suggesting malaria ought to first endure malaria-related exams relatively than a broad vary of unrelated investigations.
Dr Ngoga additionally pressured the significance of professionalism and medical ethics.
“We’ve been taught to hear fastidiously to the affected person, perceive what could be inflicting the issue, study the affected person correctly after which do investigations to substantiate what we predict.”
Sufferers inspired to ask questions
Dr Ngoga stated sufferers even have an necessary function to play of their care.
With better entry to well being data on-line, sufferers have gotten extra engaged in understanding therapy choices.
He inspired them to hunt clarification every time they don’t perceive why a check, process or admission has been beneficial.
“You’ll be able to ask questions. You’ll be able to say, 'I'm attempting to grasp. What is that this check for? Is it going to assist?'”
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Healthcare suppliers, he added, ought to be capable to clarify investigations and procedures in language sufferers perceive, serving to them make knowledgeable choices whereas strengthening belief.
Questions over prescribing practices
Considerations lengthen past hospital admissions and diagnostic exams.
A number of healthcare stakeholders stated higher-priced medicines are typically offered as higher choices regardless of the provision of lower-cost options with comparable therapeutic worth.
Some additionally recommended pharmaceutical advertising and marketing and provide chain dynamics could affect prescribing behaviour, though such claims stay tough to confirm.
They pressured that prescribing ought to be pushed by medical want, scientific proof and affected person welfare—not business issues.
Unnecessarily costly prescriptions can place extra monetary pressure on sufferers and insurers, notably in personal healthcare settings.
Balancing prices and high quality care
Healthcare spending is changing into an growing concern for insurers in Rwanda and globally.
Rising prices typically lead insurers to tighten claims evaluations, modify premiums or introduce stricter authorisation necessities, growing administrative burdens for suppliers and sufferers alike.
Hospitals, in the meantime, face mounting operational prices, together with medicines, medical tools and specialised employees.
The problem for policymakers, insurers and healthcare suppliers is to make sure sufferers obtain crucial care whereas minimising waste and stopping abuse.
Stakeholders say belief stays the cornerstone of the healthcare system, constructed on acceptable medical choices, correct claims and well timed reimbursement.
They advocate stronger digital methods, higher documentation, common audits, better transparency in prescribing and billing, and clearer communication amongst sufferers, suppliers and insurers.
Affected person involvement in therapy choices, they add, is one other necessary safeguard towards pointless healthcare prices.
For Mujawase, the expertise has modified how she approaches medical choices.
“I nonetheless belief docs, however now I do know it's necessary to grasp why one thing is being accomplished and whether or not it’s actually crucial.”
