What you need to know:
- Some of the hospitals have been suspended while others are under active investigation by the Ethics and Anti-Corruption Commission.
- The report lays bare how hospitals claim millions of shillings from the fund on services they did not perform.
Details have emerged on how hospitals contracted by the National Hospital Insurance Fund (NHIF) to provide services under the EduAfya programme pocketed a total of Sh82,554,481 million through fictitious claims lodged using forged documents.
A report presented to the National Assembly Public Petitions committee by NHIF chief executive Elijah Wachira has revealed how hospitals from 27 counties were paid as high as Sh33 million using forged letters.
Some of the hospitals have been suspended while others are under active investigation by the Ethics and Anti-Corruption Commission (EACC).
The report reveals how between 2020-2023, the health facilities faked introduction letters from schools in order to lodge claims from NHIF while others treated non-existent students whose details the fund could not trace.
According to the report, some hospitals have pre-printed introductory letters from various schools bearing the name of the principal and secretary of the board of management but have no dates.
These facilities then just key in details of students claiming they have treated them and demand payment from NHIF.
The report lays bare how hospitals claim millions of shillings from the fund on services they did not perform. For instance, some hospitals claim that they admitted students for a number of days while in reality, the students were treated and discharged.
More shockingly, the report has unearthed how hospitals edited MRI pictures to include other patients it did not treat in order to get more money from the fund.
Investigations done by NHIF revealed that Oljabet Medical Centre in Laikipia county that has since been suspended by the fund was paid Sh946, 300 using forged introductory letters.
Mr Wachira told MPs that apart from suspending the facility, the fund has so far recovered Sh916, 300 with a balance of Sh30, 200 still pending.
Still in Laikipia county, Sipili maternity also forged introductory letters and was paid Sh1,762,800 while another claim of Sh7,039,956 was rejected due to demand induced treatment done through unaccredited sanatoriums and missing records.
In Embu county, three health facilities, Queens and kings hospital, chest and skins and Kiritiri medical healthcare have been indicted for making questionable combined claims worth Sh4.6 million.
For Kings and Queens’s hospital, NHIF has already recovered Sh118, 000 that was paid to the facility for unwarranted inpatient admissions on EduAfya.
The fund also paid Sh1, 248,000 to Chest and skins though the facility failed to produce complete clinical records for the services offered to EduAfya beneficiaries of 1,248 claims
The fund has, however, recovered Sh3, 326,000 that was paid to Kiritiri medical healthcare after investigations revealed that the facility failed to produce 2,218 clinical records for the services rendered.
Mr Wachira told MPs that all the three facilities are currently suspended.
In Nandi county, Meswo (tunza) medical services was paid Sh977, 400 but investigations have since revealed that the facility made the claims using fraudulent and unwarranted visits, offered medical services in uncredited service points and there was fraud in the biometric details in terms of impersonation.
The report indicates that NHIF has so far recovered Sh788,295 from the facility which has also been suspended from offering any services under the EduAfya programme until the balance of Sh189,105 is recovered.
In Nakuru, the report has singled out three hospitals namely Familia bora medical, Naivasha quality healthcare and Bingwa family clinic that made bogus claims to NHIF.
For Familia bora medical, the report says it lodged fictitious claims worth Sh309, 000, offered services in non-accredited service points and there was also lack of document control from schools.
The fund has already recovered Sh298, 900 from the facility leaving a balance of Sh10, 100
Naivasha quality healthcare also claims worth Sh447, 600 but upon investigations it was found that the facility offered services in non-accredited service points, and did not adhere to contract amounts. NHIF has recovered the entire amount.
Bingwa family clinic was found to have lodged ficticous claims coupled with unwarranted visits worth Sh218,000. NHIF told MPs that the entire amount has since been recovered although the facility remains suspended.
It was also found to be offering poor services to members.
“Management to take action against Bingwa Afya for violating clause 6.2 of the contract by launching claims offered in non-accredited service points,” reads the report. In Nyamira Ccounty, Nyamira Jamii medical was paid Sh490,000 worth of claims that were lodged fraudulently using non-accredited and non-contracted services providers. The entire amount has however since been recovered although the facility remains suspended.
In Nairobi county, Equity Afia Buruburu was paid Sh7,191,000 though investigations have revealed that the facility had numerous questionable claims.
For instance, the report reveals that at Buruburu girls it was found that the school has pre-signed introductory letters and 3,855 students visit to the facility worth Sh5, 782,500 could not be accounted for.
Introductory letters from schools are important since it is the basis that NHIF uses to confirm details of students while processing payment claims made by hospitals.
At Huruma girls, it was found that the facility has stationed a nurse at the school. The same case with St Aquinas High School hence it was not possible for the hospitals to make claims of treatment of the same students.
The investigations revealed that 905 students visited but their details could not be traced. The total amount paid to the hospital was Sh1, 357,500
The fund told MPs that it has so far recovered Sh7,173,053 from the facility that has also been suspended from offering services under the EduAfya programme.
Still in Nairobi, Ruai medical centre was paid Sh286,000 but there were no records of the patients it treated. The entire amount has since been recovered.
Further Meridian medical dental centre was paid Sh816,000 but were found to have breached the EduAfya contract scheme by visiting Githunguri Girls and Ruchu Girls to offer services instead of treating students at the facility.
The health facility also failed to provide case notes of treatment for audit review.
“It was observed that the facility does not maintain case notes for patients (students) as required but instead maintains a listing of the patient names against which diagnosis are recorded. On enquiry by the team, it was observed that this listing originates from the nurse attached at the school by the facility for processing of claims,” reads the report.
In Murang’a county, Murang’a High School dispensary is on the spot after it was paid Sh4, 256,000 but the claims could not be supported.
In Nyeri’s Mathingira medical centre, the investigations raised questions over Sh4, 053,500 that it was paid.
“The physical patients’ files are not maintained as evidenced by a request made to the facility to avail 13 patients’ files which were not provided. It was observed that the facility does not maintain a filing system that helps to trace and retrieve patients’ files,” reads the report.
“There was no clinical data provided to show the laboratory investigations done as well as data on previous hospital visits,” reads the report.
The fund has since recovered Sh1, 106,600 and also suspended the facility from the EduAfya programme.
In Nyeri county, Thuti medical clinic was paid Sh2,065,500 despite having been found to have poor record-keeping of patient files and also had unsupported claims.
The fund told MPs that it has since recovered Sh1,534,500 from the facility and also suspended it from the EduAfya programme.
In Laikipia county, three hospitals are on the spot for lodging claims despite various anomalies such as using forged introductory letters, missing records, students whose details could not be traced at the Ministry of Health records among others.
Charity medical centre was paid Sh548, 000 but was found to have used forged introductory letters of students and there were also missing records of learners. The fund has since recovered Sh532, 519 from the facility.
Investigations revealed that Oljabet hospital annex used forged introductory letters to be paid claims worth Sh3, 220,500. A total of 2,651,500 has since been recovered by the fund from the facility.
Further the fund is holding claims worth Sh45 million as they were found to be emanating from unaccredited school’s sanatoriums
Elburgon maternity home was also paid Sh362,000 despite investigations revealing that there was non-adherence to contract amounts and services were also offered at non-accredited facilities.
The fund has so far recovered Sh28, 200 from the maternity home.
The report shows that Bama nursing maternity home in Siaya county was Sh234,100 for overstated admission and claims paid above the contract rate.
The fund told MPs that it has suspended the facility and forwarded the case to investigative agencies with a view to prosecute Bama Nursing and maternity hospitals and two clinicians for breach of NHIF Act and penal code.
In Kilifi county, Venoma medical reproductive health services was paid Sh118, 000 but was found to have double claims and all the records of the students were also missing. The funds are yet to be recovered.
In Migori county, two hospitals-Kehanchia mother and child and St Akidiva memorial hospital are on the spot over lodging fraudulent and fictitious claims and were paid Sh2, 902,000.
At Kehancha mother and child, the report shows it engaged in fraudulent activities by lodging fictitious claims. In addition, patient files for surgical cases were not tabled for review and all patients were not recorded in the theatre register book provided by the facility.
Mr Wachira told MPs they are trying as much as possible to seal all loopholes in order to avoid paying fictitious claims to hospitals. He admitted that each day, fraudsters are also coming up with new means to ensure they get money from the fund through dubious means.
“As you are sealing loopholes in one area, fraudsters are also looking for new ways to continue getting money fraudulently,” Mr Told MPs
The programme was launched in 2017 as a new health scheme, through a presidential directive in order to cater for public secondary students.