How SHA plans to stop hospital fraud
Pedestrians walk past the rebranded Social Health Authority (SHA) building in Nairobi on October 1, 2024.
What you need to know:
- In the past, NHIF staff were in charge of licensing hospitals and manually lodging the claims in the system.
- Hospitals also faced bottlenecks in claims processing, resulting in delayed payments and overstretched resources.
Hospitals will now be contracted through an electronic procurement system under the Social Health Authority (SHA) unlike the previous manual process that was prone to fraud.
Medical Services Principal Secretary Harry Kimtai has revealed that the manual contracting process that was prone to inefficiencies, manipulation, and delays will be abolished.
“With the SHA's e-system we will streamline operations, reduce corruption, and enhance transparency in healthcare service provision,” Kimtai said.
In the past, National Health Insurance Fund (NHIF) staff were in charge of licensing hospitals and manually lodging the claims in the system.
This was criticized for fostering favoritism and manipulation in claim approvals, leaving many healthcare providers frustrated by slow reimbursements and mismanagement.
Hospitals also faced bottlenecks in claims processing, resulting in delayed payments and overstretched resources, particularly for critical services such as dialysis and oncology treatments.
Mr Kimtai gave an example of a hospital in Turkana County that had to manually send their claims to Nairobi for processing and the delays that the hospitals went through.
“By the time you start processing claims so much time is gone and hospitals run out of patience. They have already invested the money and they are not getting a return on their money. With the new system, the staff will no longer conduct any business with SHA but with the system will,” he said
”We changed the law, it was NHIF staff who would move around hospitals doing the inspection, lodging that in the system, and this led to manipulation, hospitals were paid for services that they do not offer, institutions rated highly,” he said.
With the electronic system, he said, a competent authority, a government regulator will regulate the practice including the licensing of the facilities and the practitioners.
“Once the hospitals and practitioners are licensed and approved. It is the responsibility of SHA to immediately enter into a contract with the facilities without any delay and that’s why we advise them to use e-contracting for efficiency," he said.
The Ministry of Health has, therefore, directed that registration of all contracted health facilities to the new system be done by Friday.
“By digitising the contracting process, SHA promises a more efficient and transparent system that minimizes human intervention in claim approvals and hospital contracts. This will enable hospitals to upload claims directly into the system, which will automatically process the data and trigger payments based on pre-set conditions, significantly reducing delays that previously plagued the NHIF,” Kimtai said.
He assured the hospitals that moving forward, payment of claims will not be delayed since the current system can monitor claims as they come with the system as of yesterday capturing Sh100 million worth to be paid to hospitals.
“We have given a directive to SHA that they need to pay the claims within 90 days. This will bring confidence and satisfaction to everyone. We want sanity to ensure that those who are investing in the business should be sure of the returns they are getting so that they can grow,” he said.
In the past, audits exposed how four hospitals allegedly pocketed hundreds of millions of shillings in NHIF fictitious claims for patients they never treated.
Covering the 2022 and 2023 period, the investigation accuses the health facilities of fraud including altering and falsifying information in collusion with some NHIF staff members and NHIF card holders to pocket Sh700million.
Some of the patients that the hospital reported to have admitted were found to be at their places of work at the same that they were admitted.
For the last 16 days after the transition, several healthcare facilities across the country are still grappling with technical difficulties in accessing the SHA portal, leaving some providers unable to submit claims for services rendered since the new system’s rollout.
The adoption of the new system has been slow, leading to a backlog of claims and frustrated healthcare workers.
Mr Kimtai, however, said that all claims that hospitals recorded after the transition will be paid.
“If a hospital treated a patient after transition, the claims will be refunded," he said.
Last week, some hospitals reverted to using the old NHIF system while SHA worked on resolving the glitches in the new platform.
Patients, too, felt the impact. Some who had previously relied on NHIF services for critical treatments like dialysis and cancer care are concerned about potential delays in their treatment.
"We acknowledge the challenges, but we are confident that once the system is fully functional, it will significantly improve the efficiency of healthcare services in the country. It was a start but we have since solved the issues," said Kimtai.
