Health Cabinet Secretary Mutahi Kagwe has asked the National Health Insurance Fund (NHIF) to review its regulations to seal medical fraud loopholes.
According to Kagwe, the biennial review will enable the fund to seal loopholes that some dishonest health service providers have been using to enrich themselves at the expense of Kenyans.
“The review will also enable the NHIF to periodically increase its funding pool to match the rise in treatment costs,” Kagwe said in a statement.
NHIF will be the driver of the Universal Health Coverage which will make fundraisers to cater for hospital bills a thing of the past.
“At the moment, it is common to see even Kenyans deemed to be well-off organising a fundraiser whenever a family member falls sick,” Kagwe said.
Kagwe supported the decision by Senate to reduce the penalty for fraud from Sh1 million to Sh100,000 or a six-month jail term stating that this would encourage more Kenyans to report on fraudsters.
“While it is important to punish and deter fraudsters, it is equally important not to be seen as being too punitive as this reduces the willingness of the public to report fraudulent activities,” Kagwe said.
In May last year, NHIF flagged 15 health centres across the country for trying to defraud it of Sh27 million.
The Sh27,271,028 cases were detected between February and March, 2021, one of the top cases involving a facility in Kirinyaga.
According to NHIF Chief Executive Officer Peter Kamunyo, the fraudsters were mostly presenting claims for fake surgeries.
The claims usually involve making of documents, specifically MRI and CT Scans.
One of the claims forwarded by a hospital in Nairobi involved a woman who tried using her daughters’ card claiming services worth Sh1,246,007.
In September last year, Kamunyo revealed that the insurance loses Sh10 billion every year through fraudulent claims.
According to Kamunyo, the funds are lost through impersonation and fictitious claims by public and private hospitals thus denying millions of deserving Kenyans quality health care.
He cited the case of a woman who used her NHIF card in Eldoret, gave it to her mother to seek treatment at a health facility in Kitengela and Nairobi Hospital, and later the cardholder used it at Coptic hospital, all within a month.
“We realised it when we were told the patient’s mother died, then as we were processing the payments, the same card was used by the owner who had delivered at Coptic hospital, so through the different activities we got to know that different people had used it,” he said.
The CEO said some hospitals present claims of major surgeries when a patient has undergone a minor procedure.
The NHIF Amendment Bill 2021, which is awaiting President Uhuru Kenyatta’s assent, allows the agency to review funds paid to contracted facilities once every two years.