The National Assembly has directed medical cover providers for teachers to present a clear policy document, detailing procedures for handling members.

The Committee on Education also put the scheme providers in a spot over complaints of poor services, substandard medication and long turn-around time.

The MPs also sought an explanation on the role of Bliss Healthcare after it emerged that they serve the roles of master capitator as well as service provider.

“What I want you to note is that we have drugs dispensed as generic and as branded. Complaints have been raised, where teachers are granted substandard drugs,” committee Chairperson, Julius Melly told Medical Administrators Kenya Ltd and Bliss Healthcare yesterday.

But Bliss Chief Executive Officer Felix Wanjala dismissed claims on poor quality of drugs, saying none of their clients had complained.

“We are always responding to our clients and any complaint raised is always addressed in terms of service. If an MP has anyone with a case we will address it,” he said.

“I do not want us to mix quality and generic. Let me pick an example of Panadol. It is the simplest that we know. Panadol is a brand name, but since it was the first molecule to be created so we call it an original molecule. Then, someone else comes and makes the same molecule that is called generic.” 

Dr Wanjala also dismissed reports of delay, saying that the turn-around time is always one hour.

But the MPs disagreed, insisting they had received complaints that it takes a lot of time before teachers and other beneficiaries are attended to as they wait for approvals.

Medical Administrator Kenya Chief Operating Officer, Parmanand Mishra, also insisted that the scheme had removed the need for pre-authorisation for acute outpatient visits. 

He said 96 per cent of admissions and discharges are approved within 30 to 45 minutes.

According to Mishra, additional documentation may be requested to validate the treatment request in cases where potential irregularities are flagged, which may affect the turnaround time.

“This measure is essential in safeguarding members’ benefits and protecting public funds from misuse or fraudulent claims,” he said.

The companies explained the steps being undertaken to address coverage gaps in the scheme, especially with regards to high cost procedures, chronic disease management and advanced medical treatments.

Mishra said the scheme provides comprehensive coverage, insisting that all necessary costs are covered within members’ applicable limits.

He added that the scheme has a network of 763 accredited service providers across all 47 counties and in areas where private healthcare facilities may be limited, the consortium has partnered with county government health institutions.

On payment of healthcare providers, Mishra said said the Teachers Service Commission had paid for the scheme up to November 30, last year.

However, funding from the Exchequer for the quarter beginning December 1 and second quarter, which started on March 1 had delayed.

“This delay has affected the timely settlement of claims to service providers for services rendered during this period. While 36 providers have temporarily suspended services due to delayed payments, over 95 per cent of the 763 contracted providers continue to serve members,” he said.

Mishra, however, said they received the monies last week and the processing was underway to ensure the facilities have their dues by next week.