Hospitals under spotlight over NHIF fictitious claims scandal

Four hospitals are on the spot for using fraudulent means to siphon millions of shillings from Kenyans through fictitious claims.

The institutions administered treatment to unsuspecting older people who had National Health Insurance Fund (NHIF) cards, a new audit has now revealed.

NHIF undertook the investigations between 2022 and 2023. It targetted St Peter’s Orthopedic and Specialty and Jekim Hospital Nkubu – both in Meru County – and Nairobi’s Beirut Pharmacy and Medical Centre and Amal Hospital Limited.

According to the audit, the hospitals altered and falsified information in collusion with some rogue NHIF staff members and NHIF cardholders to pocket over Sh700 million illegally and corruptly.

The audit tabled before the departmental committee on Health, which is currently investigating the rot at NHIF, reveals how some patients denied being treated at the hospitals, with some saying they were not aware the institutions existed.

Employers of some of the purported beneficiaries also confirmed that the workers were at work during the entire period they are claimed to have been admitted while others were on leave.

The audit findings come as NHIF upheld the suspension of the four hospitals from the list of contracted health facilities.

Surgical speciality

With regards to St Peter’s Orthopedic and Surgical Specialty, the audit shows that the facility received Sh1.63 billion, the highest amount, representing 22.8 percent of the amount paid to the hospitals.

The audit findings come as NHIF upheld the suspension of the four hospitals from the list of contracted health facilities. The report notes that 96.2 percent of the claims submitted by the hospital were on major surgeries and specialized surgeries.

Between February and May, the hospital lodged Sh175.98 million in claims for 608 specialized surgeries and Sh12.48 million for processing for the 676 major surgical cases.

According to the report the hospital had unwarranted payments of 1,265 claims worth Sh379.9 million after it was issued with comprehensive contract to offer outpatient, inpatient and surgical packages including specialized surgeries running from July 1 2018 to June 30 2021 despite being non comprehensive by virtue of being Type C which is contrary to the communication from the department of Benefits and Contracting.

“The facility should pay back the Sh379.92 million received since it was in Level 4 and did not qualify to undertake specialized surgery during the 2018/ 2021 contracting cycle,” the audit recommends.

The audit shows that a perusal through 82 patient files St Peters Orthopedic and Specialty worth Sh17.58 million for the period September 27, 2022 and November 16, 2022 showed that 57 claims of Sh11.73 million had different dates of admissions between NHIF records and hospital files.

Reads the audit: “The admissions were to be clinically verified by branch Quality Assurance Officer before submission to NHIF for processing. This means they were not adhering to the 24 hours notification requirement and officers processing claims did not do due diligence.”

The audit noted that of 47 beneficiaries from the 82 recipients only eight members confirmed to have been picked from their home and returned by the hospital vehicles after undergoing specialised surgery while 20 visited the facility on their own where surgeries were undertaken and 19 did not respond to calls.