Insurer to put on hold enhanced schemes
MPs have directed the national insurer NHIF to stop providing enhanced schemes and instead focus on providing a comprehensive benefits package for all Kenyans.
The call came on the day lawmakers directed Auditor General Nancy Gathungu to conduct a special audit of the schemes within six months.
Members of the Health Committee in particular want Gathungu to zero in on the usage, management and payments made out of the Edu Afya Scheme between 2019 and 2022.
They also want the Ethics and Anti-Corruption Commission to establish whether there was collusion between hospitals, schools and NHIF staff to defraud the EduAfya Scheme through fraudulent claims.
A report tabled by the committee says the national insurer should focus on providing comprehensive benefit packages for all Kenyans, including civil servants.
The report shows there was an increase in claims in managed schemes.
Claims in EduAfya increased from Sh841.22 million in 2019/2020 to Sh3.5 billion in 2022/2023.
Risk of fraud
The risk of fraud, the report says, was higher in the enhanced schemes such as EduAfya, as demonstrated by the high number of reported fraud cases by service providers under investigation.
The report: “Services in the schemes were mostly offered by level Two facilities, most of which lacked the infrastructure for biometrics.”
The committee’s decision follows submissions by stakeholders that the Claims Management Division was adversely mentioned by whistle-blowers, who claimed that it facilitated fraud in its function of pre-authorising surgical procedures and other requests.
It was alleged that Judith Karimi Otele had been sponsored by service providers to travel to India as an inducement for approval of overseas treatment at the facilities of these service providers.
Reads the report: “Otele under oath informed the committee she had never travelled to India. However, her passport indicated she had travelled to India in February 2020 with an entry on 8th and an exit on 14th. She again travelled to India in May 2022 with an entry on 20th and an exit on 25th.”
The committee also observed that between June 2019 and March 2020, she travelled to Uganda, South Korea, Malaysia, Canada, Switzerland and Thailand.
The committee also said that a reliable source had said that Otele was also involved in approving surgical and other pre-authorisation requests though the internal audit failed to flag her involvement in approvals as a risk.
