The Ministry of Health has disclosed that, among other fraudulent actions carried out by healthcare facilities, Ksh.20 billion has been lost through the National Health Insurance Fund (NHIF) scheme due to fabricated claims and phony surgeries.
Health Cabinet Secretary Wafula Nakhumicha exposed the scandal involving health facilities in a statement on Friday. She stated that 27 of the 67 audited hospitals nationwide had been suspended due to Ksh—171 million in losses from the NHIF program.
According to CS Nakhumicha, irregular processes in about 40% of the nation's hospitals (3,440) have resulted in losses of Ksh.20 billion.
The CS listed fraudulent activities in operation run by the recently announced Social Health Authority (SHA), including cases of induced demand directed at vulnerable citizens like older people, induced sickness where facilities would fraudulently activate dormant member accounts, and funding medically unnecessary treatments.
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According to her, places like Nairobi, Meru, Nyahururu, Muranga, Kerugoya, Makueni, Tharaka Nithi, Subukia, Nanyuki, Bungoma, Chuka, and Machakos were among those where older people were most frequently targeted.
The CS went on to say that some facilities would have fictitious records that purportedly showed members undergoing significant surgeries while working. Still, others would employ security guards from licensed security firms and pay them to give false information about their biometrics.
Nakhumicha stated that the ministry also found irregularities in which facilities that could only perform two eye surgeries daily performed between 10 and 22 surgeries. She pointed out that this raises concerns about the veracity of claims and the available resources of these facilities.
The ministry also discovered another fraud involving the EduAfya cover, in which it was found that medical facilities had been luring in healthy students and rewarding them with food incentives in exchange for their biometrics, leading to significant financial losses.
The ministry has assured the public that there will be a return to integrity in healthcare delivery, stating that Ksh. 17.7 million of the Ksh. One hundred seventy-one million dollars lost have already been recovered in the claims recovery process.
Several hospitals that were immediately accused of engaging in fraudulent activities under the NHIF scheme and have since implemented recovery plans are as follows:
Jekim Medical Center, Queens and Kings Hospital, Charity Medical Center, St. Peter's Orthopedic and Surgical Specialty, Amal Hospital Ltd., Beirut Pharmacy and Medical Center, Jekim Hospital Meru, Joy Nursing & Maternity, and Kiritiri Medical Healthcare.
Lenmek Hospital, Equity Afia Buruburu, Mathingira Medical Center, Ruai Medical Center, Thuti Medical Clinic, Meswo (Tunza) Medical Services, Familia Bora Medical, Naivasha Quality Healthcare, Bingwa Family Clinic, Elburgon Nursing Home, Nyamira Jamii Medical, St. Joseph Shelter of Hope, and others.
