Hospitals Up the Corruption Game by Swindling NHIF Funds Using Tough Medical Terms

Kenya is a country of smart thieves, and now hospitals have joined and upped the corruption game by leveraging their use of tough medical terms to swindle the National Hospital Insurance Fund (NHIF).

In a country where everyone seems to want to stay ahead of the corruption, hospitals are changing the game to amass wealth from the national health insurer.

According to a report by the NHIF, instead of using simple terms like cleaning a cut wound using saline, hospitals describe the procedure as “tendon repair or debridement” to make it sound like a surgical procedure yet it only translates to the removal of damaged tissue or foreign objects.

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The insurer noted that hospitals are magnifying the seriousness of an issue and they cited a perfect example to give a clear picture of how the facilities are being dishonest.

“We once came across someone whose left leg was amputated according to his last hospital visit but there, he was standing on his two feet with another medical need,” Julia Ouko, the NHIF Principal Health Contracting said.

That is not all, the NHIF also stated that these medical facilities now admit their own staff under false pretense to swindle insurance funds.

“We have noted of cases where a hospital has ten staff and at one point all the staff were admitted as patients in the same hospital,” said Gilbert Osoro, NHIF Manager overseeing Benefits and Contracting.

One other trick that was identified as a method used by hospitals to steal funds is through the double billing of a patient to show that the doctor performed two procedures.

For instance, a patient will be billed twice for a procedure like an appendectomy, that is, the surgical removal of the appendix under severe cases.

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First, the hospital will bill laparotomy, the incision (cut) made by the surgeon to access the appendix, then appendectomy itself. In a nutshell, the hospital bills the procedure first as if it were an independent medical case.

There are also cases of patient impersonation where these healthcare facilities use the same card for patients sharing the same name. Eventually, the NHIF ends up paying for false claims.

Hospitals in Nairobi, Central Kenya, some parts of Nyanza, and Coast have been identified as the leading areas notorious for such cases.

Statistics show that in the financial year 2016/2017, the insurer paid a total of 1.7 billion shillings to hospitals for major surgeries for 18,201 cases.

In 2017/18 the amount surprisingly catapulted to a whopping 5.6 billion shillings for 59,318 cases.

Consequently, the payout for minor surgeries also rose from 269.9 million shillings for 7,319 cases to 667 million shillings for 19,991 cases.

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The exact figure of the amount paid by the NHIF for fictitious claims could not be revealed. However, the Directorate of Criminal Investigation is probing fraud cases where 10 billion shillings might have been paid out as a result of fictitious claims in collusion with NHIF staff.

Osoro acknowledged that some NHIF staff might have colluded with the health facilities for the fraud cases stating that the issue has risen particularly with the increase in benefit packages.

Currently, the NHIF has 13 packages including Edu Afya, the government-sponsored package for secondary school children, and dialysis from four packages in 2015.

“In fact, with the rollout of Edu Afya, we have realized a rise in the cases of students visiting hospitals, which begs the question are they genuine cases or is there an outbreak of some disease?” queried Osoro.

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As a result of the fraud cases, the NHIF is looking into 80 hospitals linked with the fictitious claims to determine whether the procedures indicated on patients’ bill were actually performed or not.

Seven hospitals have so far been suspended by NHIF in the past two years following fraud cases. However, the hospitals couldn’t have it and they took the matter to court.