- It has said those culpable will face prosecution or forfeit of any monies acquired.
- Health Cabinet Secretary Susan Nakhumicha said the facilities were among 67 hospitals that were audited between January and December 2023.
Image: Alice Waithera/FILE
Ethics and Anti-corruption Commission (EACC) says anyone involved in the alleged fraudulent activities that resulted in a loss of Sh171 million at NHIF will be dealt with accordingly.
This, the agency, said includes prosecution or forfeiture of any monies found to have been acquired illegally from public coffers.
“The commission has been investigating this matter. Culpable public officials, private persons and entities will be dealt with in accordance with the law,” it said on X.
Ministry of Health confirmed on January 5 that the national insurer lost Sh171 million due to sham activities following an audit that was conducted in 27 health facilities between January to December 2023.
Health Cabinet Secretary Susan Nakhumicha said the facilities were among 67 hospitals that were audited between January and December 2023.
“Extrapolating this to the total population of 8,886 hospitals, it is estimated that approximately 3,440 might have been engaged in fraudulent activities, potentially exceeding Sh20 billion in losses from about 40 per cent fraudulent hospitals. Luckily 60 per cent carry out clean business,” she stated.
In a statement to media houses, the CS noted that the 27 facilities have been making fraudulent claims from the National Health Insurance Fund (NHIF), which was recently replaced by the Social Health Authority.
“The widespread nature of these alleged fraudulent cases is deeply concerning. The list of implicated facilities includes instances of induced demand, particularly targeting vulnerable citizens, notably older individuals,” she stated.
She said the alleged fraud occurred in facilities in Nairobi, Meru, Nyahururu, Muranga, Kerugoya, Makueni, Tharaka Nithi, Subukia, Nanyuki, Bungoma, Chuka, and Machakos.
“Patients have been enticed into unnecessary medical procedures, exploiting their vulnerabilities,” the CS stated.
She said instances of induced sickness have been uncovered, wherein facilities deceitfully activate dormant accounts of members, financing medically unwarranted treatments.
She added that fictitious records, manufactured claims, and deceptive practices, such as falsely indicating members undergoing major surgeries while actively at work, have all contributed to allegedly defrauding the Fund.
“Disturbingly, some hospitals have targeted groups of security guards from licensed security firms, financially inducing them to provide biometrics for alleged fraudulent purposes,” she stated.
The CS further said anomalies were also identified, including facilities conducting an exceptionally high number of eye surgeries in a day, ranging from 10 to 22, in facilities with a capacity of only two per day while lacking adequate theatre capacity.
“Such discrepancies raise significant doubts about the legitimacy of claims and the resources available at these facilities,” Nakhumicha explained.
The CS noted that Under the EduAfya cover, healthcare facilities have been enticing healthy students, providing food incentives for their biometrics that result in high financial losses.
“Additionally, cases involving nurses stationed in schools collecting biometrics of non-ill students to lodge fictitious claims have been unearthed, significantly exploiting the scheme,” she added.
Nakhumicha said the Authority is determined to reduce and eliminate alleged fraud by automating services to minimise human interface.
She said the ICT systems are intended to have strong business intelligence modules to be able to flag outliers and double payments in time.
“As we collectively tackle this crisis, we reaffirm our commitment to fortifying and safeguarding the integrity of our healthcare system,” she said.
The CS assured that the government, in collaboration with relevant stakeholders, will ensure those responsible for reprehensible actions are brought to justice.