•Nakhumicha noted although there’s solid evidence against the 27 hospitals, at total of 3,440 health facilities might have been engaged in fraudulent activities, potentially exceeding Sh20 billion in losses.
•One facility relied on services of doctors who were, at the time, not authorised by the KMPDC to conduct procedures they claim to have done, NHIF said.
One lazy January evening, a security guard in Nairobi was lounging at work waiting for the long day to end. Then a colleague shared a too-good-to-be-true plan.
If he visited a certain hospital in Eastleigh with his NHIF card, he would be paid Sh10,000 instantly.
He did this early the next day. Workers at the facility took his finger biometrics, paid him and he went back to work, he told investigators.
At the end of April last year, the hospital lodged claims worth Sh910,000 to the NHIF indicating the security guard and six other colleagues were admitted there for several days.
Investigators from the National Health Insurance Fund have scoured records of the security firm and found the guards were all at work on the days they were supposedly 'admitted.'
The hospital in Eastleigh is one of the alleged rogue hospitals the NHIF has suspended for allegedly defrauding the public insurer of at least Sh171 million, in total.
Another facility also in Eastleigh was on the spot after Workers of another security firm revealed that they were approached by someone to visit the facility for a similar deal, which they did.
At the end of March this year, the facility management lodged claims worth Sh1,300,000, indicating the guards had surgeries, and some broken limbs and were admitted.
In total, the NHIF is demanding Sh15.4 million it says the hospital was paid for possible fictitious surgeries and non-existent admissions.
The NHIF audit report, which was earlier released to MPs in July last year, was reshared by Health CS Susan Nakhumicha on Friday.
It reveals how the managers of many health facilities have exploited poorly paid security guards and high school students, paying them to participate in criminal activities to defraud the public.
“Between January and December 2023, out of 67 audited hospitals, 27 were found to be involved in fraudulent activities, resulting in a loss of Sh171 million,” Nakhumicha told journalists at Afya House.
“The identified facilities have been suspended, and recovery of fraudulent claims is proceeding,” she said.
She noted although there’s solid evidence against the 27 hospitals, a total of 3,440 health facilities might have been engaged in fraudulent activities, potentially exceeding Sh20 billion in losses.
One facility is accused of exploiting children in school. The NHIF audit suggests that the medical centre in Meru has been ferrying students to its facilities for services they probably did not need.
“For the period 1st July 2021 to 19th June 2023, the healthcare provider raised claims worth Sh7,000,565. Edu Afya was the most utilised scheme in the facility at 3,177 claims totalling to Sh3,177,000,” the report said.
The investigation team visited a Girl's school in Meru on June 23, 2023, where 21 students confirmed that they were picked up on Mondays, Wednesdays and Fridays by a private white Nissan van to the medical centre and back after treatment.
At another boy's in Meru, 15 students interviewed revealed that a private Nissan van white in colour transports sick students daily to the hospital and back.
NHIF says such practices, akin to touting in the matatu industry, are illegal.
Nakhumicha said under the EduAfya cover, healthcare facilities have been enticing healthy students with food for their biometrics, resulting 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 said.
Other deceptive tricks are even more worrying. NHIF sampled some patients it says only had some since small incisions and steroid injections were made at another health facility in Mwea.
However, the hospital filed claims for knee, hip or shoulder arthrotomies. This is a surgical exploration of a joint, which should include inspection of the cartilage, inside structures, joint capsule, and ligaments.
The facility also relied on the services of doctors who were, at the time, not authorised by the Kenya Medical Practitioners and Dentists Council to conduct procedures they are said to have done, NHIF said.