Some Kenyans might have missed out on receiving timely medical care due to unjustified authorisation rejections for valid requests by the defunct National Health Insurance Fund.
A report by the Ethics and Anti-Corruption Commission presented on Tuesday has raised concern that some requests from patients that had previously been rejected showed a later approval.
The fund’s Case Management Division assesses the medical necessity for admissions and procedures through the preauthorization process and advises healthcare providers accordingly.
For instance, the report showed a request made and rejected on September 11, 2023, was later approved after a subsequent request was made using the same records on September 26, 2023.
"This denied patients opportunities for early access to critical care thus exacerbating conditions requiring timely interventions," EACC said in the report.
"It may also increase the cost of healthcare due to resultant complications."
According to the report, the processing of all requests from across the country was centralized at the NHIF headquarters.
It was being managed by officers whose primary professional backgrounds included nursing, clinical officers and lab technologists.
The team attends to a daily demand of approximately 5,000 requests.
Since 2017, EACC data shows that 4,795,313 requests had been received out of which 164,302 were pending, 51,843 were cancelled, 49,539 expired, 1,189,268 were rejected and 3,340,361 had been approved by September 2023.
According to the report, the Case Management Division prepared a work allocation schedule for preauthorization requests based on case codes.
EACC has warned that this system of assigning specific preauthorization requests to an officer creates backlogs and avenues for processing erroneous and fictitious claims.
"Lack of diversity in medical specialisation within the preauthorization team is a weakness that may lead to rejection of claims without proper medical dimension; delay and denial of services to eligible beneficiaries; out-of-pocket payments by beneficiaries and difficulty in identification of medical fraud," the report says.
The report further notes that stipulated timelines of 48 hours for responding to preauthorization were not observed.
The delays have resulted in the rescheduling of procedures by some patients while some had to incur additional expenses by either staying in the hospital for longer periods than necessary awaiting the procedures to be preauthorized or paying out of pocket for urgent medical interventions.
Speaking while receiving the report at NHIF headquarters, Medical Services PS Harry Kimtai noted the report will aid in restructuring the systems being currently put in place through the Social Health Authority.
He said the key areas of focus will be on weak points in the procedures established in the report and ensuring operations of SHA put in place will support and ensure there is no more fraud in the claims which has affected NHIF for long.
"We have been having challenges especially providing services to our beneficiaries who have paid," Kimtai said.
"The time it takes for them to get service because it requires pre-authorisation takes time for one to get authorisation, it takes for a facility to be empanelled to the NHIF."
EACC chairperson David Oginde said the commission was invited to look at the systems, and the operations of NHIF and find out any loopholes that need to be sealed so that the loss of resources is reduced or eliminated.
The commission undertook the process for two months looking at the systems, operations and how the various stakeholders interact with one another.
Oginde said some of the key findings include a weak framework for prevention prevention in the fund
"We found that the systems were such that they lend themselves to people who are corrupt to take advantage of the system," he said.
The report recommends that the authority should consider onboarding diverse medical specialities to facilitate the pre-authorisation function.
It also recommends that the level of automation is enhanced to improve turnaround time, ensure minimal human intervention and conceal identifiable information associated with all requests to curb favouritism and selective service delivery.
