- The national health insurer stated that it has investigated at least 20 private facilities in the last one year.
- But the facilities have shifted the blame to NHIF, saying that there was no way they could be involved in fraud without the help of the agency.
Image: EZEKIEL AMING'A
The National Hospital Insurance Fund and some private hospitals are engrossed in a bitter blame game over fraud claims as senators probe alleged collusion that has cost taxpayers millions of shillings.
This emerged during a Senate Health Committee meeting on Thursday where NHIF admitted that there has been collusion between a section of its staff and some private medical facilities.
The national health insurer stated that it has investigated at least 20 private facilities in the last one year and established massive fraud, leading to suspension of licenses of some facilities.
But the facilities have shifted the blame to NHIF, saying that there was no way they could be involved in fraud without the help of the agency.
“These are claim processes for NHIF which show how hard it is for a facility to defraud NHIF without help,” Kenya Association of Private Hospitals chairman Abdi Mohammed said.
While appearing before the Jackson Mandago-led committee, NHIF chief executive officer Elijah Wachira said there are a number of corrupt and fraudulent practices being perpetuated by the private medical facilities across the country.
Wachira held that some of the facilities submit separate claims to the fund for services that could fit on a single bill, while others process more patients to increase their revenue through suggesting further check-ups that may not be essential.
“Between July 2022 and June 2023, some 27 healthcare provider contracts have been suspended on violations relating to corrupt and fraudulent practices,” Wachira told the committee.
Wachira said Afya Bora Hospital, Afya Bora Annex (Joy Nursing and Maternity Eastleigh), Jekim Hospital Nkubu and Jekim Medical Centre were flagged for suspected fraudulent activities in November last year and a desktop investigations initiated in February 2023.
In his submissions to the committee, Wachira stated that the fund received complaints against St Peter's Orthopaedic and Specialty Centre, Amal Hospital Limited and Beirut Pharmacy and Medical Centre regarding patients' records and non-compliance with contractual obligations.
“The desktop investigations and employer interrogation established more than 90 per cent fraud risk at the providers,” he said.
He added, “The right of reply was granted but could not be administered since the providers filed a commercial suit, which is pending determination. The contracts remain suspended."
However, Dr Wasena Angira of St Peter's Orthopaedic and Surgical Specialty Centre charged that although NHIF sent a team of investigators into the facility for audit, they are yet to receive communication from the fund.
Angira further told the committee that apart from NHIF, Kenya Medical Practitioners and Dentist Council also sent a team of investigators and cleared the facility to continue operations.
“We were suspended on June 2023 following a media report that we were involved in embezzlement of NHIF fund. NHIF sent their team to do an audit but so far, we have received no response from them.
"The DCI also came to do an investigation. We have not received any response,” Angira said.
He further stated that after the expiry of 90 days' suspension, NHIF did not communicate until November 1, 2023, when they were given a letter dated October 2023 that allows further one-time suspension of 90 days, which expires on December 20, 2023.
In order to curb such unethical and fraudulent practices in the health sector, Rural Hospitals Association of Kenya proposes the establishment of an independent medical review board or panel within the NHIF or its successor the Social Health Authority.
“We propose that such a board or panel shall be staffed with respected clinical leaders drawn from professional medical associations (such as the Surgical Society of Kenya, the Kenya Orthopaedic Association, the Kenya Obstetrics & Gynaecology Society), to determine, in the event of a dispute, the "medical necessity" of procedures and claims,” said RUPHA national chairman Dr Brian Lishenga.