How new medical scheme hopes to evade fraudulent claims

The process of phasing out the National Health Insurance Fund (NHIF) is on course after registration of the new Social Health Insurance Fund (SHIF) kicked off on Monday, July 1.

The latter years of NHIF’s close to six decades of existence have seen the loss of billions of taxpayer money, due to unverified claims made by hospitals seeking reimbursement for services provided to patients covered by the scheme.

A report by the Auditor General, Nancy Gathungu, shows that NHIF paid Sh368 million in excess as part of claims made by hospitals in June 2023, while blaming it on ‘typing errors’ by the hospital clerks.

According to President William Ruto’s advisor on health financing, Dr Daniel Mwai, SHIF has instituted safeguards that will prevent fraudulent claims such as double billing through measures such as the ongoing digital registration to capture verifiable data.

“The biggest entry to fraud for NHIF has been poor data stored. There is no single source of truth. I can be Daniel and have another person’s identity,” said the health adviser on Spice FM.

“To deal with that, SHIF links data collected at the registration stage with the National Reference Bureau where every person’s biometrics are stored. We simply verify by linking to the unique identification of the person,” he added.

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In stark contrast, SHIF is establishing a providers’ registry where all approved facilities will be enlisted with clear details of the level of care they provide and the cost of services they offer to prevent exaggeration of charges by the facilities.

Dr Mwai says that Social Health Insurance Fund is already in talks with facilities including privately owned and faith-based hospitals to be enlisted with Kenyans not limited to hospitals to attend under SHIF.

“At the core of NHIF woes was the issue of costing of services. That has been done more correctly and transparently now. They are being published in the papers now so that people can see the benefits they are entitled to and their costs,” he said.

The government aims to make access to quality healthcare universal more equitable with all households contributing 2.75 percent of monthly income.

Unlike NHIF, SHIF will make all the benefits of the cover known to the policy holder including information on the usage limits for each of the services.

Further, the government aims to ensure that all policyholders are able to make claims by making SHIF the primary scheme therefore being charged first where one has two insurance covers as is the case with complimentary insurance among many civil servants.    

Kenyans, and foreigners, registered to the Social Health Authority (SHA) via USSD code *147#, web self-registration on the SHA website or in NHIF offices and at Huduma Centres will start benefitting from the revamped SHIF services on October 1,2024.