Insurance Companies

Health insurers compete on price while medical costs rise faster than premiums. Sustainable growth depends on disciplined product design and underwriting, efficient claims management, reliable data and strong relationships with healthcare providers.

OGHC combines clinical insight with claims and data experience, so recommendations are medically sound as well as financially sensible — from repricing a product to automating claims with appropriate human oversight.

The pressures on health insurers

Across Kenya and the wider region, medical schemes face the same squeeze: treatment costs, new technologies and growing chronic disease push claims up, while corporate clients and individuals resist premium increases. At the same time, statutory reforms — such as Kenya's move from NHIF to the Social Health Authority — change how private cover fits alongside public schemes, and regulators expect sharper reporting and fairer treatment of members.

Most insurers already hold the information needed to respond. The difficulty is that it sits in separate claims, underwriting and finance systems, so questions such as "which benefits are driving our loss ratio?" or "which providers bill outside expected patterns?" take weeks to answer.

Where OGHC helps

Product design and pricing. Benefit structures, limits, co-payments and waiting periods reviewed against claims experience, so products stay competitive without hidden losses. Support for new products for SMEs, individuals and corporate groups.

Claims management and cost containment. Review of claims workflows, pre-authorisation rules and medical necessity criteria; claims audits on a sample or full basis; and practical controls that reduce leakage without delaying genuine care.

Provider networks and tariffs. Network design, provider performance analysis, tariff benchmarking and preparation for negotiations — giving your team evidence rather than anecdote.

Fraud, waste and abuse. Identification of unusual billing patterns, duplicate or inflated claims and inappropriate referrals, with clear rules for escalation to qualified reviewers. Flags support human decisions; they never replace them.

Data, analytics and reporting. Loss-ratio and utilisation dashboards by product, client, benefit and provider, built on your own data and handed over with the methods documented.

Digital and AI-enabled operations. Assessment of where automation and AI can safely speed up claims intake, document processing and member service — with governance, data protection and human oversight built in from the start.

Regulatory and statutory change. Analysis of how reforms affect your products, members and corporate clients, and practical options for adapting benefit design and communication.

How an engagement usually works

1. Diagnostic. We agree the questions, review data and processes, and interview the teams involved.
2. Findings and options. A clear report with quantified findings where the data allows, and prioritised, costed recommendations.
3. Implementation support. Help with pricing changes, new claims rules, dashboards, provider negotiations or training — as much or as little as you need.

Engagements can be a focused review of one product or process, or a broader programme. All work is confidential, and member-level data is handled under a data-processing agreement and Kenya's Data Protection Act.

Questions insurers often bring to us

• Why has our loss ratio risen on one corporate scheme but not others?
• Are our outpatient limits and co-payments set at the right level?
• Which providers or procedures account for most of our cost growth?
• How should our products adapt alongside SHA cover?
• Where could automation reduce claims turnaround without increasing risk?