When NHIF lets you down in hour of need

NHIF

Patients have been faithfully paying for their insurance cover from NHIF and getting a raw deal when they eventually need it.

Photo credit: File | Nation Media Group

What you need to know:

  • NHIF works on a capitation model and its sustainability is dependent on massive enrolment. In the past, it has demonstrated its capacity to serve Kenyans.
  • Apart from past allegations of corruption at the level of top management that saw the CEO dismissed, the institution has been riddled with lower level corruption claims.

Karen* has been a faithful contributor to her National Hospital Insurance Fund (NHIF) cover for the past 10 years and never once has she needed to use it.

However, upon review, Karen was diagnosed with fibroids which means she needs to undergo surgery. The necessary paperwork was done and filed by the hospital to NHIF, seeking preauthorisation for the surgery to proceed. Three days later, NHIF approved half the cost of surgery. Her appeal to NHIF to cover the full cost fell on deaf ears. The surgery has not been done.

Last week, Loice*, a newly pregnant mom walked into the clinic with an emergency. She was having a miscarriage and bleeding heavily. She is a civil servant and a contributor to the enhanced NHIF civil service scheme. She has not had any problems with her medical cover previously, but on this particular day, she could not benefit from it. This procedure did not require Loice to be admitted.

She had to pay for her treatment in cash before discharge and later claim reimbursement from the hospital when NHIF made approvals. It took four days before NHIF communicated its approval. Despite having an in-patient benefit cover of 1.9 million, NHIF refused to pay her bills in full and only approved Sh30,000. This was less than half the cost of her treatment. When the hospital followed up with NHIF, the response was that the hospital works within that budget. Loice was essentially denied the benefit she pays for every month.

Pauline* called me on a Tuesday afternoon. She was 32 weeks pregnant and had broken her waters. She was having contractions. Her baby was definitely preterm and we needed to get to the hospital and fast. At review in the hospital, the baby was in breech presentation and together with the prematurity, required a caesarian delivery.

Corruption claims

The paperwork for Pauline as an enhanced NHIF civil service scheme beneficiary was done and filed with immediate effect but the approvals came after two days with the same circus of partial payments. The baby was still in the newborn unit struggling with prematurity.

This has become the norm through most of 2020 and getting worse towards the close of the year. Patients faithfully paying for their insurance cover from NHIF and getting a raw deal when they eventually need it. As if this is not enough, NHIF now will not pay for Covid-19 treatment.

This is the same institution that as Kenyans, we have all put our faith in for the past five years. An institution whose vision is to be a world class universal social health insurer. One that has spent millions in enrolment drives, convincing all Kenyans who are unemployed to sign up for the NHIF Supa cover. As healthcare workers, we strongly advocated it and encouraged Kenyans to join.

NHIF works on a capitation model and its sustainability is dependent on massive enrolment. In the past, it has demonstrated its capacity to serve Kenyans.

However, the goings-on in the house on Capitol Hill are leading us to many questions. Why does NHIF not have a standard cost price for procedures? Other than the standard Linda Mama, all other products are unpredictable. NHIF will approve various amounts for patients variably for the same hysterectomy. One will get Sh150,000 while another gets Sh80,000. What is the rationale?

Apart from past allegations of corruption at the level of top management that saw the CEO dismissed, the institution has been riddled with lower level corruption claims. Those on the civil service scheme have found their covers maximally used up following hospital admission yet their bills were minimal.

Plug leaks

Others have found out they have listed dependents on their membership card whom they do not know. Some institutions used specialist doctors’ credentials without their consent, to get approvals for procedures that should be done by specialists. These procedures are then done by resident non-specialist doctors, putting patients in harm’s way.

Patients have been denied their right to choose their preferred hospital or doctor. This is a direct contravention of the constitutional right of every Kenyan to freedom of choice. Further it contravenes the Patients’ Rights Charter which states that a patient has a right to choose their preferred healthcare provider.

As NHIF continues to make effort to plug these leaks, a few recommendations will help improve service for all. Like other health insurance providers, have a standard cost price for services that apply across all institutions.

Let the patient choose where they wish to spend their money and top up from their pocket if they need to. Further, technology is your friend. Just like the self-service portal has created transparency for the contributors, a similar one for doctors who recommend admission will be useful.

Meanwhile, where did the money we pay go?

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