NHIF Fraud: Sh20B Lost Through Fraudulent Claims In 2013, Ministry Of Health

Health Cabinet Secretary Nakhumicha S. Wafula disclosed Friday that the government has identified facilities that have been defrauding the National Health Insurance Fund (NHIF).

The CS says an audit recently carried out by the Social Health Authority (SHA) reveals shocking details of hospitals that dishonestly pocket billions of shillings of taxpayers’ money through fictitious claims.

“Between January and December 2023, out of 67 audited hospitals, 27 were found to be involved in fraudulent activities, resulting in a loss of Kes 171 million,” she said

“Extrapolating this to the total population of 8,886 hospitals, it is estimated that approximately 3,440 might have been engaged in fraudulent activities, potentially exceeding Kes 20 billion in losses from about 40% fraudulent hospitals. Luckily 60% carry out clean business,” Nakhumicha explained

According to the CS, the facilities in question employed numerous tricks to defraud the Fund.

One such scheme is where patients have been enticed into unnecessary medical procedures, exploiting their vulnerabilities.

“Instances of induced sickness have been uncovered, wherein facilities deceitfully activate dormant accounts of members, financing medically unwarranted treatments,” said the CS

While justifying reform of the fund, Nakhumicha says fictitious records, manufactured claims, and deceptive practices, such as falsely indicating members undergoing major surgeries while actively at work, have all contributed to defrauding the Fund.

“Disturbingly, some hospitals have targeted groups of security guards from licensed security firms, financially inducing them to provide biometrics for fraudulent purposes,” she said

“Anomalies have also been identified, including facilities conducting an exceptionally high number of eye surgeries in a day, ranging from 10 to 22, in facilities with a capacity of only 2 per day while lacking adequate theatre capacity. Such discrepancies raise significant doubts about the legitimacy of claims and the resources available at these facilities,” she charged

Problem with Edu Afya

At the same time, the CS highlighted corruption in Edu Afya, a comprehensive medical scheme that was previously meant for all public secondary students.

“Under the EduAfya cover, healthcare facilities have been enticing healthy students, providing food incentives for their biometrics that result in high financial losses,” she said

“Additionally, cases involving nurses stationed in schools collecting biometrics of non-ill students to lodge fictitious claims have been unearthed, significantly exploiting the scheme,” stated the CS

Nakhumicha says all facilities linked to fraud in NHIF have been suspended.