•Some private facilities have been pocketing at least 60 per cent of all NHIF payouts every year.
•The proposed regulations also push private health insurers to pay their fair share of medical costs.
Image: MAGDALINE SAYA
NHIF will no longer pay for the treatment of chronic diseases in private hospitals if the newly-published regulations are approved.
The move to lock out private facilities is aimed at controlling runaway costs, where some private facilities have been pocketing at least 60 per cent of all NHIF pay-outs every year.
“A beneficiary with chronic illness shall access treatment from public health care providers only,” the fund said in draft regulations on claims and benefits, published by Health CS Mutahi Kagwe on Wednesday.
The National Health Insurance Fund did not give its definition of chronic illness.
However, the World Health Organization says this is a long-term health condition that cannot be prevented with vaccines, may not have a cure and cannot be passed from person to person.
The commonest chronic diseases include cancer, heart disease, stroke, diabetes, asthma and arthritis.
The fund has previously been criticised for paying more to the few contracted private health facilities, compared to public facilities.
Out of the Sh37 billion paid to facilities in 2019, private hospitals pocketed Sh22 billion.
Public hospitals got Sh7 billion, while faith-based hospitals got Sh8 billion.
Health CS Mutahi Kagwe said pay to private facilities has been spiralling without justification.
Claims by contracted facilities jumped from Sh19.7 billion in the financial year 2015/2016 to Sh54.6 billion in the financial year 2020/2021, Kagwe said.
The draft regulations authorise the NHIF board to revoke contracts of providers who intentionally prescribe unnecessary medical procedures to patients.
“A healthcare provider that intentionally prescribes unnecessary medical procedures to beneficiaries commits an offence and shall be liable, upon conviction, to the penalty stipulated in section 45 of the Act and the board shall revoke the empanelment of the healthcare provider,” the draft says.
On October 6 last year, Health CAS Mercy Mwangangi said private facilities were the main culprits in this malpractice.
“We have seen complaints of patients who go to hospital and come out with a draft sheet of procedures to be done,” she said.
“What we are doing is coming up with a system of pay that bundles the tests. For example, if a patient is being treated with diabetes, NHIF will know the tests that will be required for that.”
The proposed regulations push private health insurers to pay their fair share of medical costs.
Currently, hospitals bill NHIF first before private insurers, for co-insured members.
“A beneficiary shall declare to the board within 24 hours upon seeking services where they have a private insurance cover,” the regulations say.
“The private insurance shall provide a written confirmation to the board where the benefits have been exhausted.”
Last year, NHIF boss Peter Kamunyo told The Star the standard globally is for private insurers to pay first for people co-insured with a social scheme.
In total, the fund released five sets of draft regulations to the newly-amended NHIF Act on Wednesday.
They cover Beneficiary Identification, Contributions, Member Registration, Empanelment and Contracting, and Claims and Benefits.
The documents are available on the NHIF website.
Edited by Kiilu Damaris