Seven health facilities have been suspended and 80 others are under investigation for alleged fraud against the National Hospital Insurance Fund.
The national insurer has suspended the seven in the past year from offering services.
Some hospitals have been billing both patients and the NHIF, while cases of impersonation and some hospitals making fraudulent claims using members’ cards are on the rise.
Majority of the fraud cases under investigation involve overstating of claims, manipulation of the documents of non-existing hospitals and pharmacies, or cover-up and non-disclosure of medical facts at the proposal stage.
The insurer noted that healthcare fraud, waste and abuse directly contribute to the need for higher premiums.
“Fraud leads to the shrinking of the available benefit package to members,” Benefits manager Gilbert Osoro said.
Addressing the media at the NHIF headquarters in Nairobi yesterday, Osoro said the management has taken note of the increase in the magnitude of the risk by re-engineering the claims process to enhance efficiency and effectiveness in payment processing for legitimate claimants.
He said to curb possible fraud, the NHIF will invest in new futuristic technology that allows for review, investigations, and timely payments of the claims.
The system will replace the earlier approach referred to as pay-and-chase for recovery of payments which had loopholes for possible fraud and abuse.
Osoro asked healthcare providers to work with NHIF in minimising fraud by avoiding unnecessary services. “They should report cases of billing services that were never rendered, billing for brand name when generic were dispensed, overstating of admission days, billing for a costlier service than the one actually performed,” he said.
NHIF has in the past raised the alarm over increased medical fraud from both private and public health institutions. Assistant Claims manager Judith Otele called on Kenyans to desist from sharing their cards with relatives, saying it amounts to fraud on the side of the beneficiary.
The insurer did not however disclose the names of the suspended health facilities, saying they challenged the decision in court.
They will be named after the court’s verdict.