National Health and Insurance Fund (NHIF) acting CEO Samson Kuhora is on the spot over the alleged fraudulent claims and payments to various hospitals.
Dr Kuhoria on Tuesday found himself in the hot seat after legislators launched a 90-day inquiry into the alleged rot at NHIF following claims of medical fraud in Nairobi and Meru counties.
A media expose revealed how eight medical facilities siphoned millions of shilling from the Fund allegedly aided by senior staff. The same is said to be happening across other counties.
The Endebess MP Robert Pukose-led National Assembly Health committee yesterday accused the acting CEO of either being behind the fraud or doing little to fix the rot at NHIF.
Moyale MP Jaldesa Guyo pressed Kuhora to shed light on how dubious claims were generated and paid without the NHIF doing due diligence.
"All that we are investigating lies with the CEO and he needs to come clear on the facilities that were charging twenty or more times than the approved rate," said Guyo.
The MP also alleged that prior to Kuhora's promotion three months ago he was working in a department where he allegedly aided the fraud.
"I feel like you might have been elevated to acting CEO to conceal what you have been doing... Unless you prove otherwise, in your position three months ago, what we are investigating is what you were doing before being elevated," he said.
The CEO however refuted the claims saying that NHIF had already taken action by suspending contracts with six hospitals for a period of 90 days.
Kuhora revealed that investigations into Beirut Pharma and Amal Hospital in Eastleigh had been completed and it was established that they had been involved in fraud. For the other six facilities, he said, investigations are still ongoing with a report expected within three months from July 16.
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"Prior to my promotion, I worked in the data analytics department and did not case management which is in charge of claims payments approvals," stated Kuhora.
He was however at pains to explain why approximately 60 per cent of the payments to the hospitals involved in fraud had been approved by one officer from the case management division.
Kuhora also found it difficult to fight off allegations that some officials from NHIF had now colluded with hospitals outside the country, such as those in India, in a well-orchestrated scheme to loot from the public coffers.
This was after Kenya Pharmaceuticals Distributors Association Chairperson Kamamia Murichu told the committee that lack of internal controls at NHIF to ensure verification of the amounts in claims had led to the alleged loss of public funds.
"There is a gross abuse of the claims process because many facilities charge exorbitant prices for drugs that they did not administer to patients. If a facility prescribes generic drugs to a patient for instance, it in turn claims for the price of an original drug which is way higher," said Dr Murichu who was also concurrently appearing before the committee.
"It appears that there is no one from NHIF who bothers to verify the price of drugs as contained in the claims and that is how they end up paying out billions," he added.
Nyeri Town MP Dancun Maina sought to know whether NHIF had conducted market research on the prices of drugs.
Kuhora responded," we have not conducted market research because we rely on an Essential Medicine List system which guides us."
At the same time, it has emerged that NHIF made losses amounting to approximately Sh6 billion due to the non-remittance of premiums by the government.
Finance officer at NHIF Francisca Mwanza told the committee that the funds' claims reserves had decreased from Sh15 billion in 2021 to Sh8 billion in 2023. This, she explained, was a result of the decline in investments due to a delay in remittance by the national and county government.
Seme MP James Nyikal faulted NHIF for giving government institutions services on credit which he said was sinking the fund.
"Isn't it discriminatory and against the law that when voluntary NHIF contributors default on payment you not only deny them services but also penalize them yet for government schemes you allow them to operate on credit?" Dr Nyikal posed.
The acting CEO however noted that the same was in line with contractual agreements between the fund and both levels of government.
The committee is expected to continue with the probe with the Health Cabinet Secretary scheduled to appear before it.
