A staggering Ksh.20 billion was siphoned off through fraudulent activities within the National Health Insurance Fund (NHIF) scheme in a scandal that involved 40% of NHIF-accredited hospitals which received capitation from the public medical insurance agency in 2023.
The shocking NHIF scandal report, which was revealed by the Ministry of Health, shows that this sum was lost through a variety of deceptive practices including manufactured claims and fabricated surgeries carried out by health facilities.
Health Cabinet Secretary Susan Nakhumicha dropped this bombshell in a statement on Friday, January 05.
According to the CS, out of 67 hospitals audited across the nation, a staggering 27 have been suspended due to their involvement in the loss of Ksh.171 million within the NHIF scheme.
Activation of dormant accounts and fake claims
The CS who spoke to the press at the Ministry of Health headquarters in Nairobi said the accused health facilities deceitfully activated dormant accounts of members and pushed for the payment of unwarranted cases.
The accused facilities also manufactured medical claims, and applied deceptive practices to access funds.
Nakhumicha further highlighted the scale of irregular processes in the country’s hospitals, revealing that approximately 40% of the total number of hospitals, a massive 3,440 facilities, were engaged in fraudulent activities resulting in the massive Ksh.20 billion losses.
“Between January and December 2023, out of 67 audited hospitals, 27 were found to be involved in fraudulent activities, resulting in a loss of Ksh.171 million,” she stated, further underscoring the widespread nature of the malpractice.
NHIF scandal targeting elderly innocent citizens
The newly established Social Health Authority (SHA) spearheaded an operation that unearthed various fraudulent activities.
These included tactics such as induced demand targeting vulnerable groups like the elderly, falsified activations of dormant member accounts, and financially motivated, unnecessary treatments.
Elderly citizens were particularly targeted in areas such as Nairobi, Meru, Nyahururu, Muranga, Kerugoya, Makueni, TharakaNithi, Subukia, Nanyuki, Bungoma, Chuka, and Machakos, according to Nakhumicha.
The CS revealed shocking tactics used by some facilities, including creating fictitious records indicating members undergoing major surgeries while they were still actively at work.
Additionally, some facilities employed licensed security guards and financially incentivized them to provide biometrics for fraudulent purposes.
Moreover, anomalies were found where facilities with a limited capacity to conduct surgeries were inexplicably performing a significantly higher number of procedures, casting doubt on the legitimacy of claims and available resources.
EduAfya cover for students
The ministry also uncovered fraudulent activities within the EduAfya cover that was meant for students. Healthy students were enticed with food incentives so as to provide their biometrics, resulting in substantial financial losses.
“Cases involving nurses stationed in schools collecting biometrics of non-ill students to lodge fictitious claims have been unearthed, significantly exploiting the scheme,” Nakhumicha disclosed.
Despite the colossal losses, the ministry has assured the public of ongoing efforts to restore integrity in healthcare provision.
Numerous hospitals have been implicated in the scandal, with efforts underway to recover lost funds.
A recovery of Ksh.17.7 million out of the Ksh.171 million lost in the NHIF scandal has been retrieved so far.
Some of the hospitals on the spot for fraudulent activities through the scheme, and where recoveries have since been instituted include;
- Jekim Hospital Meru
- Jekim Medical Centre
- Joy Nursing & Maternity
- Amal Hospital Ltd
- Beirut Pharmacy and Medical Centre
- St. Peter’s Orthopedic and Surgical Specialty
- Afya Bora Hospital Annex Ltd in Mwea
- Charity Medical Centre
- Queens and Kings Hospital
- Chest & Skin Clinic
- Kiritiri Medical Healthcare.
- Meswo (Tunza) Medical Services
- Familia Bora Medical
- Naivasha Quality Healthcare
- Bingwa Family Clinic
- Elburgon Nursing Home
- Nyamira Jamii Medical
- St. Joseph Shelter of Hope
- Lenmek Hospital
- Equity Afia Buruburu
- Muranga High School Dispensary
- Mathingira Medical Centre
- Ruai Medical Centre
- Thuti Medical Clinic.
