The Ministry of Health has disclosed how the National Health Insurance Fund (NHIF) scheme lost over Ksh20 billion through fraudulent activities within health centers.
Through a statement released on January 5, Health Cabinet Secretary Susan Nakhumicha announced suspension of 27 hospitals over the fraudulent loss of Ksh171 million through the scheme.
The disclosure comes nearly a day after CS Nakhumicha acknowledged significant fraud within NHIF.
“The claim records received by the Ministry from private hospitals unmistakably reveal extensive fraud, perpetrated through the issuance of fabricated patient records,” said Nakhumicha.
According to the statement, the loss in billions of shillings was through fake surgeries and manufactured claims among other fraudulent activities.
NHIF fraud
“Between January and December 2023, out of 67 audited hospitals, 27 were found to be involved in fraudulent activities, resulting in a loss of Ksh171 million,” read part of the statement.
Out of 8,886 hospitals, the statement revealed, approximately 3,440 might have been engaged in fraudulent activities.
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However, CS Nakhumicha revealed that the identified facilities have since been suspended, and that recovery of fraudulent claims was underway.
Furthermore, the statement revealed that the new Social Health Authority (SHA) is concerned about the widespread fraud in health centers.
The statement further revealed, “The list of implicated facilities includes instances of induced demand, particularly targeting vulnerable citizens, notably older individuals.”
Fraudulent activities
Patients have been enticed into unnecessary medical procedures, exploiting their vulnerabilities.
Furthermore, instances of induced sickness were uncovered, where facilities deceitfully activate dormant accounts of members, financing medically unwarranted treatments.
Also, fictitious records, manufactured claims, and deceptive practices, such as false major surgeries’ all contributed to defrauding the NHIF, according to the ministry.
Additionally, anomalies have also been identified, including facilities conducting an exceptionally high number of eye surgeries in a day.
Some facilities, according to the revelations, were found to have conducted surgeries ranging from 10 to 22.
Contrastingly, the identified facilities contained a capacity of only 2 surgeries per day while lacking the adequate theatre capacity.
Similarly, healthcare facilities were found to have also been involved in fraud under the EduAfya cover.
“Healthcare facilities have been enticing healthy students, providing food incentives for their biometrics that result in high financial losses,” revealed the statement.
Additionally, cases involving nurses stationed in schools collecting biometrics of non-ill students to lodge fictitious claims have been unearthed.
Social Health Authority
Notably, the statement further disclosed that the findings were part of a mandate assigned to the Social Health Authority (SHA).
Earlier in October 2023, SHA was established under the Social Health Insurance (SHI) Act 2023 to replace NHIF.
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Furthermore, all funds, assets and properties previously held on behalf of NHIF were vested into the new authority.
According to the statement, one of the Authority’s mandates is to address and rectify systemic issues perpetuating fraudulent activities.
“The Authority is envisioned to reduce and eliminate fraud by automating services to minimize human interface,” reads the statement.
In turn, CS Nakhumicha revealed that SHA aims at ensuring the realization of Universal Health Coverage (UHC).
Furthermore, the MOH has disclosed that the government is resolute in ensuring that those responsible for these reprehensible actions are brought to justice.
