• For outpatient services, NHIF pays up to 94 per cent of bills for patients with multiple covers.
• The study shows for expensive treatments, such as complex chemotherapy, NHIF pays 66 per cent of the bill for members with multiple covers.
Image: FILE
A new study has revealed how private health insurers have been running away from hospital bills, sometimes forcing the NHIF to cover the entire amount.
Currently, health facilities must first secure National Hospital Insurance Fund preauthorisation before private insurers can commit to pay.
The NHIF says this has drained the fund and it is not sustainable.
The study shows for outpatient services, NHIF pays up to 94 per cent of bills for patients with multiple covers.
“The trend in the current benefits payout has been regarded as unsustainable in the long term if no intervention is made,” the study done by NHIF’s research and policy division shows.
At least two in every 10 members of the national insurer have an additional private medical care policy.
The study proposes the amount covered by NHIF should not cover more than 30 per cent of the bill if the patient has a private cover.
The standard practice around the world is for a private insurer to pay first, with the social insurer clearing the balance, which is often less.
The study shows that for expensive treatments, such as complex chemotherapy, NHIF pays 66 per cent of the bill for members with multiple covers.
“This has consequently contributed to high benefit payouts by the Fund,” the study says.
It is titled Impact of Multiple Health Insurance on NHIF Benefit Pay-Out at Contracted Healthcare Facilities.
NHIF CEO Peter Kamunyo said they will review contracts with health facilities.
“This will form the basis for mandating healthcare providers under NHIF to enforce fair placement of risk with other private health insurance when reviewing contracts of service provisions and payments of benefits,” he said.
This requirement is captured in the National Hospital Insurance Fund (Amendment) Bill 2021, tabled in Parliament early last month.
As at June 31, 2020, NHIF had contracted 7,969 healthcare providers, consisting of 76 per cent public, 21 per cent private and three per cent faith-based facilities.
Overall, NHIF pays 33 per cent of all bills for people with multiple insurances, the study says.
Association of Kenya Insurers CEO Tom Gichuhi said this share of the bill is peanuts.
“NHIF wants to eat its cake and have it by getting double premium income through contributions from employees and employers but then take a back seat when claims crystallise,” he said last month.
The fund says this arrangement is partly responsible for its spiralling benefits payouts.
While NHIF premium contributions increased three-fold, from Sh14 billion in 2013-14 to Sh45 billion in 2017-18, benefit payouts increased five-fold over the same period.
An analysis for the financial year 2019-20 shows that the total benefit paid out was Sh56.55 billion against a revenue of Sh58.61 billion.
However, NHIF said it will continue to pay daily rebates for admitted patients whether or not they have other insurance policies.
Currently, the daily rebate (popularly known as payment for bed), ranges from Sh1,200 to Sh4,000 depending on the category of the facility.
The study shows private insurers also force members to seek treatment in NHIF accredited facilities.
“In most instances, they have required their beneficiaries’ access care in health facilities that have comprehensive package contracts with NHIF, thereby abdicating their responsibility to their members and transferring the burden of coverage to NHIF,” it says.
Currently, approximately 44.72 per cent of Kenyans have health insurance.
Those insured by NHIF are 39 per cent, and those insured only by private insurance companies represented are 5.72 per cent.
The uninsured population is 55.28 per cent, according to the Kenya National Bureau of Statistics.
Edited by A.N