There is always a new way of doing things, and it looks like hospitals in the country are perfecting the art. According to the state agency, they are now registering fake surgeries to bring more money to the table from the National Hospital Insurance Fund (NHIF).
The scam mainly involves healthcare providers who claim to have performed various operations and procedures during surgeries when in fact they did not, either because they were not medically necessary or because they would have resulted in reduced payment claims from the insurance fund.
According to released, NHIF has so far paid Sh6.9 billion for those claims, with Sh5.6 billion going to settle major surgeries and a further Sh610 million spent on specialized surgeries. The national insurance scheme spent a further Sh667 million towards coverage of minor surgeries.
NHIF assistant claims manager Judith Otele said most of the frauds were happening through upcoding, where healthcare providers submit inaccurate billing codes to insurance companies aiming to receive inflated reimbursements.
“The healthcare providers do this in surgeries especially. For example, a patient who walks in with a simple cut is said to have needed a tendon repair. There are also cases where a woman who had a normal delivery is upcoded to a C-section,” she said.
“Some healthcare providers bill each procedure as if it were a separate procedure just so the claims go up,” said Ms Otele.
NHIF benefits and contracting manager Gilbert Osoro said there has been a particularly sharp increase in claims and amounts in Nairobi, Central Kenya, Nyanza, and the Coast.
He said there are 80 health facilities countrywide that are under investigation for their involvement in possible fraud against NHIF while seven facilities have been suspended from offering services by the national health insurer in connection to the fraud.
“They have taken the matter to court so we cannot mention them and as for the 80 facilities we are still investigating and we would not like to blow the lid,” he said.