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The National Health Insurance Fund (NHIF) and some private hospitals are now in a blame game over collusion to defraud the public of its medical funds through fictitious claims.

The revelation emerged during a Senate Health Committee meeting where NHIF admitted that there had been forms of collusion between the staff of the national health insurer and some staff of the private medical facilities across the country.

In addition, it further emerged that NHIF is fraught with systems failure, biometric failure, and delays in allowing patients to access the highest attainable medical care.

This even as some of the private hospitals claimed that the NHIF withdrew their operating licenses without any justifiable reasons.
In addition, it emerged that claims processes for NHIF will show how hard it is for a facility to defraud NHIF without help.

While appearing before the Jackson Mandago (Uasin Gishu) led committee, NHIF Chief Executive Officer Elijah Wachira said that several corrupt and fraudulent practices are perpetuated by private medical facilities across the country.

Wachira held that some of the facilities submit separate claims to the fund for services that could fit on a single bill while some process more patients to increase their revenue by suggesting further check-ups that may not be essential.

Fraudulent practices

“Between July 2022 and June 2023, some 27 healthcare provider contracts have been suspended on violation relating to corrupt and fraudulent practices,” Wachira told the committee.

According to Wachira, Afya Bora Hospital, Afya Bora Annex (Joy Nursing and Maternity Eastleigh), Jekim Hospital Nkubu and Jekim Medical Centre were flagged for suspected fraudulent activities in November last year and a desktop investigations initiated in February 2023.

In his submissions before the committee, Wachira stated that the fund received complaints against St. Peters Orthopedic and Specialty Centre, Amal Hospital Limited and Beirut Pharmacy and Medical Centre regarding patients’ records and non-compliance to contractual obligations.

However, Dr Wasena Angira representing St Peter Orthopedic and Surgical Specialty Centre charged that although the Elijah Wachira-led National Health Insurer sent a team of investigators into the facility for audit, they are yet to receive communication from the fund.