NHIF, private hospitals clash over claims

Some private hospitals are turning away patients with National Hospital Insurance Fund (NHIF) cover, citing unpaid bills by the national insurer. 

They say their claims are not being honoured by NHIF, which has forced them to resort to the drastic action with the problem persisting for months now.

But NHIF insists it has suspended the services of some hospitals that failed to meet accreditation requirements and others that are under investigation for fraudulent claims.

Dr Abdi Mohammed of the Ladnan Hospital said the measures by NHIF have been going on for close to a year and they have had to turn away patients due to rejection of their cards.

“We have been experiencing this with our clients for months. I do not know if it is a cost-cutting measure on their part. But we try to handle it the best way we can,” Dr Mohammed said. Kenya Medical Association (KMA) secretary general Simon Kigondu said there are various reasons for turning away patients including non-remittance of the statutory dues by the counties.

Turning away patients

The Kenya Private Hospital Association’s Dr Wachira Gioko traced the problem to the reclassification of hospitals.

“When the national insurance picked the report by the expert panel which informed their decisions to pick various hospitals of their choice, it has seen us fight with them in terms of contracts and other issues,” Dr Gioko said.

National Assembly Health committee chairperson Sabina Chege explained that, when the Kenya Medical Practitioners and Dentists Council took over the licensing and accreditation of hospitals, there have been issues with some hospitals especially those that do not follow due process while registering: “We have not received any complaints on our end however some hospitals did not follow due process while registering which could be a pointer to their current predicament.”

NHIF chairman Roba Duba said hospitals are turning away patients without informing them how they failed to comply with the law.

“Some of these hospitals do not disclose the real reasons why they turn away patients because they have failed to meet accreditation criteria. We have suspended services in certain hospitals because we are investigating fraud or other issues such as capitation,” Mr Duba said.

Dr Gioko explained that the Health Financing Reforms Expert Panel (Hefrep), which was set up to transform NHIF, found the national insurer's administrative costs way too high, which reflected inefficiencies in the system. The panel cautioned that the fund may start running deficits from as early as this year.

“Several county schemes also default on their premium payments. Given the trend in growth in premiums and claims, when future revenues and claims for the county schemes are projected, claims will outstrip revenues by 2026 making the county schemes unsustainable,” the panel said in its report.

Administrative costs

The main expenditure contributing to administrative costs is staff costs, comprising 54 percent in 2017/18.  Others are advertising and publicity (24 percent), travel and accommodation (10 percent), medical expenses (10 percent), and transport expenses (six percent). NHIF is fighting a different battle with governors after they demanded a stop to new registrations under the Universal Health Coverage (UHC) , saying they were not consulted.

“UHC delivery is not a function of the NHIF. It is a joint responsibility for the county governments and the national government. It follows therefore that NHIF registration cannot be done in counties without consultation with the county governments,” Council of Governors chairman Wycliffe Oparanya said in a statement.

The Kakamega governor cited the ongoing reforms at the NHIF as the other reason the county bosses were opposed to the NHIF exercise.

Being a shared institution serving both levels of government, Mr Oparanya said: “The NHIF cannot proceed to implement any health programmes in the counties without consultation with county governments.”

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