Kenyans have turned siphoning of money into a new hobby. Everything has been turned into a conduit for some people to make some millions for themselves.
NHIF card which is meant to help people cater for their medical bills has been converted conduit pipe where hospitals and doctors make extra coins illegally.
Fake surgeries now top the list of frauds against the National Hospital Insurance Fund (NHIF), the State agency has revealed.
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.
The data released Thursday showed that NHIF paid Sh6.9 billion for those claims, with Sh5.6 billion going to settle major surgeries and a further Sh610 million spent on specialised 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.
She added that the dubious schemes are affecting patients who undergo medically unnecessary procedures.
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.