NHIF, union now insist private insurers must pay hospitals more

Cotu Secretary General Francis Atwoli (right) and National Hospital Insurance Fund (NHIF) acting CEO Nicodemus Odongo consult on the fund's mandate. NHIF and Cotu have made recommendations that could see private insurers pay more for their clients. [Collins Oduor, Standard]

Fund says it should be shielded from a situation where it settles hospital bills first, before other insurers pay remainder.

Private health insurers will be forced to pay more for their policy holders if new recommendations are adopted.

The recommendations being mooted by the National Hospital Insurance Fund (NHIF) and the Central organisation of Trade Unions (Cotu), want private insurers to desist from having NHIF pay first for individuals who are co-insured, before they settle the remainder of the bill.

In a statement signed by NHIF acting Chief Executive Nicodemus Odongo and Cotu Secretary General Francis Atwoli, NHIF has demanded to be shielded from being the insurer that pays first.

“In reimbursing hospitals for all health services offered to members, NHIF should not be the first payer for co-insured beneficiaries,” read the statement.

“NHIF payments for co-insured beneficiaries should be considered after the other insurers settle their contractual obligations to their members.” The recommendations now open a new battle front between the public health insurer and private insurance companies.

Last month, Roba Duba, the NHIF board deputy chairman, argued that the current setup had seen NHIF lose funds while private insurers posted huge profits. “When a person who is co-insured goes to hospital, the first thing he is asked is if he/she is covered by NHIF,” said Mr Duba.

“If he/she is, NHIF settles the full amount it has covered, before the private insurer settles the remaining dues. NHIF ends up paying more in such a co-insurance setup.”

In the statement the Insurance Regulatory Authority (IRA) was also accused of trying to micromanage NHIF.

“We reject the misguided idea of IRA defining the schemes given to public organisations as commercial insurances,” read the statement.

“These managed schemes are not for profit and therefore cannot be treated as commercial but rather government to government partnerships.”

It went ahead to remind IRA that NHIF was an autonomous fund operating under an Act of Parliament – the NHIF Act No. 9 of 1998 – and not controlled by the Insurance Act.

In the statement the national and county governments were also urged to set up special wings in all public health facilities dedicated to NHIF beneficiaries.

NHIF and Cotu have also demanded the immediate separation of statutory and voluntary contributors.

Both entities argued that the latter group was gobbling up in excess of Sh10 billion from the fund in benefits pay-out and over-utilisation.

“Cotu calls on the government to fund the health insurance for non-statutory contributors through the Universal Health Coverage (UHC),” the statement read.

The NHIF board also directed members to choose facilities they would be seeking services from using a mobile platform.

The USSD code and the App are part of new innovations which the insurer believes will eliminate a situation where members will not have to queue at its offices to register.

Outpatient care facilities can be selected through the NHIF App or through the USSD Code *155#.

To be able to use the above options, a member’s phone number must be captured in the NHIF data base.

Payments to facilities for the first quarter of this year will be pegged on the new choices contributors will make.

National scheme members have had the entire February to select outpatient facilities.

Another window to change facilities will be opened in June and December.