NHIF admits to fraud in payment of hospital claims as Ksh.6B loss revealed

This even as it was revealed the fund suffered a Ksh.6 billion loss in the last financial year, a loss attributed to non-payment of premiums and the huge losses due to fraudulent payments.

These revelations came to light as the National Assembly Committee on Health commenced investigations into alleged fraudulent payments of medical claims and capitation payments to health facilities.

The Robert Pukose-led committee noticed a huge jump in claims especially in particular schemes sponsored by the government.

One of the main concerns was Edu Afya scheme which caters for high school students. Under this scheme, the claims have surged to Ksh3.5 billion in the last financial year from as low as Ksh.800 million 4 years ago.

“Why is there a huge increase in claims in this scheme, could it be one of the avenues being used to siphon money from the fund? Have you done any forensic audit to know the reason for the huge increase in claims?’’ Pukose posed.

While admitting to cases of fraud in the payment of claims, NHIF Acting Chief Executive Officer Dr. Samson Kuhora, said there have been several forensic audits to diagnose the root problem.

“Edu Afya is one of the schemes that has been giving us concerns, it has grown from 800 million 4 years ago to Ksh.3.5 billion. It’s one of the schemes we suspect fraud has been ongoing, we have done several audits because in this scheme most members are between 13 and 19 years and we don’t expect claims to be this high,’’ Kuhora said.

However, members of the committee insisted Dr Kuhora should not escape blame for he has been heading one of the main departments in payment of claims before ascending to be the CEO.

Dr. Kuhora, a former benefits design and claims management manager at the fund, was at pains to explain to the MPs efforts he has put in place to secure the funds remitted.

The investigation began after an expose showed how money was being embezzled from the fund through fraudulent claims. 

Last month, Health Cabinet Secretary Susan Nakhumicha suspended eight rogue health centers, including Amal Hospital Limited and Berut Pharmacy and Medical Centre, and ordered a thorough probe into the payment of these fraudulent claims.

Other suspended facilities included Jekim Medical Centre in Meru, St Peter’s Orthopaedic and Surgical Hospital in Kiambu, Afya Bora Hospital in Kirinyaga, Joy Nursing and Maternity Hospital in Nairobi, and Afya Bora Hospital Annex in Kirinyaga.

“It has been established that there was indeed fraud in terms of members who allegedly accessed services at Amal Hospital Limited and Berut Pharmacy and Medical Centre, but the investigations have also revealed that they did not actually receive any services.” Dr Kuhora told the committee.