When Madeline Mujawase took her young son to a private hospital in Kigali with what appeared to be a mild fever and flu, she expected a routine consultation, treatment and a quick return home. Instead, what began with a nebulisation session in the emergency unit turned into a four-day hospital stay, multiple tests and mounting medical bills. I took my son to hospital with a mild fever and flu. They conducted nebulisation at the emergency unit and he was improving. Later, the doctor said we needed to admit him to monitor his fever, Mujawase recalled. As a parent, my first instinct was not to question the doctor's decision, so I agreed. She expected to return home the following day. Instead, the admission dragged on. The doctor did not show up the whole day. My child remained under observation and only came during the evening shift. When he arrived, he said there was one more test to check for sinusitis. ALSO READ: Chief Justice sounds alarm over rising insurance disputes The hospital stay stretched into several days, and discussions eventually turned to surgery. At that point, I became uncomfortable with how a case that was supposed to be simple had escalated. Before we knew it, we had spent four days in hospital. Beyond disrupting her family's routine and causing missed work, the experience ended in a dispute over the hospital bill after her insurer questioned several charges. Mujawase said the insurer challenged the necessity of some procedures and declined to cover part of the bill, leaving her caught in a prolonged dispute with both the hospital and the insurance company. The back and forth was exhausting. You are already worried about your child, then you are trying to understand why certain procedures are being questioned or not covered. Her experience reflects growing concerns among patients, insurers and healthcare stakeholders over whether unnecessary admissions, prolonged hospital stays, excessive testing and questionable prescribing practices are contributing to rising healthcare costs. When treatment becomes expensive Medical experts caution that prolonged admissions and extensive investigations are not always unnecessary. Some conditions require close observation, additional tests and specialist care before an accurate diagnosis can be made. ALSO READ: Insurers' body vows to address delays in paying private health facilities However, concerns arise when interventions may not be clinically justified. Patients often lack the medical knowledge to question healthcare professionals and therefore trust that every admission, test or prescription is necessary. Industry players say this imbalance can leave patients vulnerable to avoidable costs. The consequences extend beyond the immediate bill. Medical expenses are deducted from patients' insurance benefits, meaning coverage may be exhausted by treatment later deemed excessive, forcing families to pay out of pocket when more serious health needs arise. A parent whose daughter was treated at a clinic in Kimironko, and who requested anonymity because of the sensitivity of the issue, shared a similar experience. His daughter suffered what appeared to be a minor sprain during a basketball game. What began as a simple injury evolved into prolonged follow-up care, including physiotherapy sessions that continued even after she had fully recovered and returned to sport. It was perplexing. The extra costs, including the 15 per cent patient contribution and transport, kept adding up. Yet, from our perspective, she had already recovered and was back on the court. Why claims are disputed According to Emmanuel Sabayesu, Acting Executive Secretary of the Rwanda Health Insurers Association (RHIA), disputes between healthcare providers and insurers commonly arise from coding and documentation errors, inadequate clinical records, prior authorisation challenges, patient eligibility issues and manual data-entry mistakes. He noted that insurers operate under different contractual arrangements with providers, resulting in varying claim requirements. Sabayesu said wider adoption of paperless systems and digital workflows could improve efficiency, reduce administrative burdens and minimise processing errors. While insurers say many disputes stem from administrative issues, they also maintain review mechanisms to verify that billed services were actually provided and medically justified. Healthcare providers, however, argue that the claims process has become increasingly complex. A representative of a private health facility, speaking anonymously, said hospitals must navigate multiple approval procedures, extensive documentation requirements and frequently changing insurance rules. Claims undergo several verification stages, including eligibility checks, pre-authorisation for specialised services and insurer reviews. Rejections often stem from missing documentation, discrepancies between provider and insurer records, or evolving digital claims systems. Digitisation improving claims processing The Rwanda Social Security Board (RSSB), which manages claims under the Rwanda Medical Insurance Scheme (RAMA), says reimbursements are guided by approved tariffs, ministerial instructions and contractual agreements. A revised national tariff approved by the Ministry of Health took effect in July 2025, followed by amendments in February 2026. RSSB says claims from private health facilities and pharmacies are now submitted, verified and reconciled electronically through the Integrated Health Billing System (IHBS), commonly known as Kwivuza. Public health facilities are still transitioning from paper-based processes, but RSSB says it is working with the Ministry of Health towards a fully digital system integrated across the health sector. ALSO READ: Parliament passes compensation bill: This is what it says about calculation of damages, payments Claims are verified against benefit packages, approved tariffs and contractual requirements before reimbursement. Where discrepancies arise, providers are allowed to review findings, submit supporting documents and clarify disputed services. If disagreements persist, they are escalated through internal review structures and, where necessary, referred to the Ministry of Health for mediation. RSSB says digitisation has significantly improved efficiency, reducing pharmacy claims processing from more than 90 days in 2020 to fewer than 15 days today. Similar gains are expected as more private health facilities are fully onboarded. Doctors urged to prioritise clinical judgement Brig Gen Dr Eugene Ngoga, Commandant of Rwanda Military Teaching Hospital, said sound clinical judgement should always guide patient care. Doctors, he said, should first take a detailed medical history and conduct a thorough examination before ordering investigations. Investigations are there to support diagnosis, but they shouldn't be abused. He warned against relying excessively on diagnostic tests without first establishing a clear clinical basis. There's no reason for having so many tests when we don't have any clue that this might be the problem. Modern diagnostic tools, he said, should confirm or rule out likely diagnoses—not replace clinical assessment. ALSO READ: Unpaid medical bills prompt rethink on needy patient support Doctors are trained to identify the most likely causes of illness and order targeted investigations accordingly. For example, a patient with symptoms strongly suggesting malaria should first undergo malaria-related tests rather than a broad range of unrelated investigations. Dr Ngoga also stressed the importance of professionalism and medical ethics. We have been taught to listen carefully to the patient, understand what might be causing the problem, examine the patient properly and then do investigations to confirm what we think. Patients encouraged to ask questions Dr Ngoga said patients also have an important role to play in their care. With greater access to health information online, patients are becoming more engaged in understanding treatment decisions. He encouraged them to seek clarification whenever they do not understand why a test, procedure or admission has been recommended. You can ask questions. You can say, 'I'm trying to understand. What is this test for? Is it going to help?' ALSO READ: Govt orders health facilities to treat patients before insurance checks Healthcare providers, he added, should be able to explain investigations and procedures in language patients understand, helping them make informed decisions while strengthening trust. Questions over prescribing practices Concerns extend beyond hospital admissions and diagnostic tests. Several healthcare stakeholders said higher-priced medicines are sometimes presented as better options despite the availability of lower-cost alternatives with comparable therapeutic value. Some also suggested pharmaceutical marketing and supply chain dynamics may influence prescribing behaviour, although such claims remain difficult to verify. They stressed that prescribing should be driven by clinical need, scientific evidence and patient welfare—not commercial considerations. Unnecessarily expensive prescriptions can place additional financial strain on patients and insurers, particularly in private healthcare settings. Balancing costs and quality care Healthcare spending is becoming an increasing concern for insurers in Rwanda and globally. Rising costs often lead insurers to tighten claims reviews, adjust premiums or introduce stricter authorisation requirements, increasing administrative burdens for providers and patients alike. Hospitals, meanwhile, face mounting operational costs, including medicines, medical equipment and specialised staff. The challenge for policymakers, insurers and healthcare providers is to ensure patients receive necessary care while minimising waste and preventing abuse. Stakeholders say trust remains the cornerstone of the healthcare system, built on appropriate clinical decisions, accurate claims and timely reimbursement. They recommend stronger digital systems, better documentation, regular audits, greater transparency in prescribing and billing, and clearer communication among patients, providers and insurers. Patient involvement in treatment decisions, they add, is another important safeguard against unnecessary healthcare costs. For Mujawase, the experience has changed how she approaches medical decisions. I still trust doctors, but now I know it's important to understand why something is being done and whether it is really necessary.
