Fraud in the medical schemes industry has been under the spotlight for some time, with key role players in the industry intensifying their efforts to
deal with the scourge.
The big question is whether the industry is winning on this one. What is now emerging is that there is a general consensus regarding the need for collaboration in order for the healthcare sector to effectively and efficiently address the issue.
Whether fraudulent activities are committed by the medical scheme members, or healthcare service providers, individually or acting in collusion; it is
ultimately the members collectively, who bear the brunt in the form of increased monthly contributions as schemes try to mitigate the effect of the loss suffered.
Insurance Regulatory Authority (IRA) industry release for Q2 2018 shows that claims amounted to Sh29.20 billion up from Sh28.62 billion reported during the same period in 2017.
In medical insurance, a recent Ethics and Anti-Corruption Commission (EACC) revealed that there is widespread variation in what different hospitals charge for the same medical procedures.
The EACC report showed patients using insurance cards are charged up to 50 times more than those paying in cash for the same procedure at the same health facility.
Insurance providers in the medical field have raised alarm over huge losses they incur due to the rising cost of claims by health providers. They say high medical bills are eating into their underwriting profits.
According to figures from the Insurance Regulatory Authority (IRA), the sub-sector has for the fourth time in a row recorded losses as healthcare gets expensive.
National Hospital Insurance Fund (NHIF) has revealed that some hospitals go to an extent of admitting their own staff who are under NHIF just to make that extra cash.“We have noted of cases where a hospital has ten staff and at one point all the staff was admitted as patients in the same hospital,” said NHIF Manager in charge of Benefits and Contracting.
Another trick is when hospitals double bill a patient showing the doctor did two procedures yet it can be billed as one.
In 2016/2017 financial year, NHIF paid Sh1.7 billion to hospitals for major surgeries for 18,201 cases, and in 2017/18 the amount shot up to Sh5.6 billion for 59,318 cases. The payout for minor surgeries also went up from Sh269.9 million for 7,319 cases to Sh667 million for 19,991 cases.