NHIF, hospitals on the spot over fraud running into the billions

National Health Insurance Fund (NHIF) building, Nairobi. [File, Standard]

When MPs on Monday questioned eight institutions accused of fraudulently collecting claims from the National Health Insurance Fund (NHIF), it emerged that government agencies could have colluded with hospitals to defraud patients and Kenyans' of money running into billions.

A probe by the National Assembly Health Committee placed the NHIF and Kenya Medical Pharmacists and Dental Council (KMPDC) at the center of the controversy related to bogus claims and irregularities in registration.

In a grilling led by Robert Pukose, KMPCD was found to have registered hospitals to offer services despite them not meeting set qualifications, while NHIF paid claims to hospitals without proper medical health documentation.

It was revealed that the hospitals also conducted procedures without approval, and details of members were not captured in the theatre register.

During the grilling even with alleged irregularities, hospital management applauded NHIF saying they had a good working relationship, more so with NHIF which does refund of claims.

For example at Jekim Hospital, a review of 88 inpatient files revealed 20 unwarranted admissions and long stays, whereas at Jekim Medical Center, there were 20 missing records, but claims were made and honored.

Jekim Hospital also offers orthopedic services, yet it doesn't have an orthopedic surgeon.

Keep Reading

Appearing before the Pokuse committee, Wendy Warete, administrator at Jekim Medical Center admitted that the facility has been operating without patients' medical records until November 2022, when they did acquire one.

Ironically, even after having admitted to operating without proper patient records, the facility still referred patients to respective hospitals for specialised care and treatment.

"I may not give the list today (list of patients referred)....the situation is, we do refer clients but are given prescription notes and a referral letter but we were not keeping records," Marete told the committee.

"Patients are treated at the facility, but we were transitioning into the new system, so some of the documentation might have been displaced during the transition," she said in reference to the acquisition of the medical record system by the hospital in November last year.

Jekim Medical Center was also found to have offered sick leave to students in a school located over 18 kilometers away, offering them snacks and transport to ferry tens of students to the facility for treatment.

In defense, Marete said the facility which has been operating since 2001 does not have control over patients seeking care.

Marete dismissed claims that the facility picked students from schools, saying the printed sick leave sheets and leave outs were organised by school administrations.

"Treatment is about relating with clients, we try to be in touch with clients, and they come in, and leave happy people," said Marete.

On fraudulent payment, she said the hospital attached a medical report to the NHIF system, but it may be a classical error, errors she said had been brought to her attention during the grill.

The use of wrong codes to make claims, according to the administrator was made erroneously.

"It was a clerical error. I would like to tell the committee that we've had a good working relationship with NHIF, they have no complaints with us. On codes, we had proper documentation for patients, which they (NHIF) did not raise a complaint. The new system will come a long way to bridge the gap," admitted Marete.

Jekim Medical Center. [Phares Mutembei, Standard]

She explained that during the claim, the facility provides notification to NHIF, through a biometric notification system, and notification is made to NHIF, by attaching a medical report, a process that takes approximately seven days.

The claims she said are done online, generally for all facilities in the country, where notification is reflected to both the facility and NHIF system.

On payment, Matere said the facility does not coax NHIF employees but rather asks for guidance at a closer branch.

"NHIF has a good system and is responsive to facilities, even with delays, they have not been inconvenient to facilities," she said.

Pukose took an issue with Marete's expansion maintaining that the facility made wrong claims, saying the hospital was expected to refund the money after realizing they had been paid by NHIF.

"If somebody came and paid excess money for you for selling mandazi, will you just keep the money say he has not demanded? You noted the mistake and used the wrong code and this one was already a long time ago. Why haven't you refunded money?" Posed Pukose.

Also appearing before the committee was Jekim Hospital, which caused a loss of Sh4.7 million due to anomalies in procedures performed.

The Level Four hospital is also accused of offering services without qualifications.

For example, the hospital has only four medical officers instead of the six expected to run a level-five hospital.

In defense, the hard-pressed hospital administrator Edith Gatwiri said she was not aware that some of the services offered were not authorised by KMPDC.

"I do not know chair, that the services offered were not within contract. We have no orthopedic surgeon, but have a Memorandum of Understanding (MoH) with an orthopedic surgeon to offer the service," Gatwiri said.

She added, "I am not sure of the contract entered by NHIF if it provides us to outsource for services, but we have a contract with an orthopedic surgeon. We didn't know it was cheating..."

The orthopedic surgeon contracted by Jekim Hospital, she explained, outsources orthopedic equipment with a private company to offer services to patients in need of surgeries.

Pukose noted that the hospital had 20 unwanted long stays at the hospital, whereas 22 patients had their files not tally with the history they presented, which led to a loss of Sh115,000

In response, Gatwiri told the committee, "NHIF didn't give us a report. On long stay, maybe a medical officer can answer. When a patient is in the ward, I may not know the duration they are in, and might not know the diagnosis,"

Jekim Hospital has a bed capacity of 80, which the administrator said is exclusive of Lind Mama.

Jekim Hospital Administrator Edith Gatwiri. [Boniface Okendo, Standard]

According to KMPDC regulations, a level four hospital should have at least 16 resident doctors, but Jekim Hospital only has four.

Other specialists required to run a Level Four hospital include anesthesiologists, general surgeons, ophthalmologists, nephrologists, and neurologists among others.

Banice Wairimu, administrator of Afyra Bora Medical Center was nervous and unable to defend the hospital on claims of more than Sh12 million which was done before pre-authorisation approval, late notification, and member details not captured in the theatre register.

The hospital was accused of having conducted procedures without approval, and details of members were not captured in the theatre register.

Also, the committee accused Afya Bora Hospital of conducting operations without being authorised. For example, on Feb 7, 2023, a single doctor is reported to have carried out 21 surgical cases on a single day.

The operations are reported to have been conducted despite the hospital having only two theatres that offer general services and maternity.

But in defense, Dr Wachira Wakioko, an orthopedic surgeon who represented the hospital said the operations were done by a team of doctors, and not a single doctor.

"We did the surgeries, but we are six surgeons at the facility. Maternity is never busy, we do spontaneous deliveries and usually, we aren't active. We use the theatre for general surgeries," the doctor told the committee.

Ironically, the doctor alleged to have conducted the operations was licensed by KMPDC in January this year, and employed by the hospital in February.

In 2021, the hospital is reported to have conducted seven MRI images, which were fraudulently edited to benefit 11 other patients.

NHIF further paid the hospital Sh1.7 million despite it not having MRI machines and was further paid Sh4.5 million for 20 MRI claims.

During the probe, none of the hospitals grilled admitted to conducting medical camps, despite the audit report from KMPDC linking them to the service.