How NHIF Suspended Healthcare Providers Abuse Edu-Afya Services
A report of investigations commissioned by the National Hospital Insurance Fund (NHIF) on the conduct of 17 suspended healthcare providers under the Edu-Afya initiative uncovered instances of abuse and violations.
Reports estimate that at least Sh20 million was lost.
The healthcare providers submitted claims, sometimes totaling millions of shillings, for services not rendered or lacking supporting documentation.
The report, upon which the 17 healthcare service providers’ contracts were revoked, demonstrates that they not only circumvented the law but also misused their rights.
In other instances, they conspired with some schools to deceive the government by submitting payment claims without providing services to students.
Former President Uhuru Kenyatta launched Edu-Afya, a comprehensive medical scheme for secondary school students, as part of Universal Health Coverage.
However, its implementation is the source of contention between NHIF board chairman Lewis Nguyai and CEO Peter Kamunyaro.
The chairman has accused the CEO of suspending the contracts of 17 healthcare service providers without consulting the board.
Board members who talked to Sunday Nation on the condition of anonymity confirmed that they were aware of the audit.
The research reveals that some claims were not backed by pertinent medical information and that some school-leaving forms for students lacked health records.
Some healthcare service providers did not follow contract rules or did not contain theater notes for sampling cases.
Others executed procedures and accepted students before receiving authorization, while others provided insurers with belated notifications.
In other instances, the dates of admission and discharge in patient records did not match those in the NHIF database.
For instance, highlighted in the investigation, one of the healthcare service providers claimed Sh40,000 for two maternity cases under the Edu-Afya program rather than the Linda Mama program.
In one instance, cases of outpatient care were claimed as inpatient services, resulting in the loss of Sh26,000 claimed by one of the healthcare service providers.
There were also instances in which claims were submitted for treatments other than those performed for the registered member, resulting in overpayments of between Sh70,000 and Sh120,000.
Another 3,855 alleged hospital visits by students could not be verified, resulting in a loss of approximately Sh5.78 million according to the report.
In another instance, the attendance of 905 pupils at a health institution could not be verified due to a lack of supporting documentation, resulting in the loss of almost Sh1.3 million.
This was likewise the case with another 22 trips, resulting in an additional Sh33,000 in losses. Additional 924 pupils’ hospital trips were not supported by introduction letters from school principals or their designees.
This resulted in a Sh924,000 loss.
Another 1,429 claims above the contract value of Sh1,000 were submitted, resulting in an overpayment of Sh741,500 and 120 claims totaling Sh180,000.
The study states that as a result of the detected cases, it had become impossible for NHIF to determine if the scheme provided value for money, resulting in the suspension of the aforementioned facilities.
Thirteen circumcised pupils were diagnosed with typhoid, pneumonia, severe malaria, convulsions, and diarrhea at one medical institution.
The HCP officials altered the system notifications without specifying the grounds for the cancellations, so abusing the system right.
A combined standing committee between NHIF and the ministry of education conducted the audit.
It was done in February for the coverage period beginning in January 2021 and ending in December 2022.
Following concerns that a number of these schools were misusing the Edu-Afya program, a multi-agency team was entrusted with conducting an investigation into these healthcare service providers.
In violation of the NHIF Act, Mr. Nguyai claims the CEO suspended the 17 health institutions without consulting the board.
“I have been trying to guide the CEO. My role is to guide him on the rule of law and nobody is above the law.”
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However, when contacted, Mr. Kamunyo stated that his decision was based on the law and that Edu-Afya’s suspension was part of an ongoing investigations.
Yesterday, a source on the NHIF board reported that the insurer lost approximately Sh21.2 million.
The suspension, according to the source, might be extended to between two and five years if the board finds the institutions guilty.
According to the law, any healthcare provider who commits fraud against the Fund may have their enrollment canceled and be fined Sh500,000.
Regarding schools, the Ministry of Education will make a determination.