What you need to know:
- The report, which formed the basis of the revocation of the contracts of the 17 institutions, shows that the healthcare service providers did not only bypass the law but also abused their privileges.
- The facilities made claims, sometimes running into millions of shillings, for services not provided or for those without supporting documents.
- The Edu-Afya programme is a comprehensive secondary school students' medical scheme that was launched by former President Uhuru Kenyatta under Universal Health Coverage.
A report of investigations commissioned by the National Hospital Insurance Fund (NHIF) into the conduct of 17 suspended healthcare providers under the Edu-Afya programme has revealed cases of abuse and violations, with sources indicating that at least Sh20 million had been lost.
The report, which formed the basis of the revocation of the contracts of the 17 institutions, shows that the healthcare service providers did not only bypass the law but also abused their privileges.
The facilities made claims, sometimes running into millions of shillings, for services not provided or for those without supporting documents.
In other cases, they colluded with some schools to defraud the government by making claims for payments without attending to students.
The Edu-Afya programme is a comprehensive secondary school students' medical scheme that was launched by former President Uhuru Kenyatta under Universal Health Coverage.
Its implementation is, however, at the centre of tension between NHIF board chairman Lewis Nguyai and CEO Peter Kamunyo.
The chairman has accused the CEO of suspending the contracts of the 17 institutions without involving the board, but some board members who spoke with Sunday Nation in confidence said they were aware of the audit.
The report shows that some claims were not supported by relevant medical documents and sometimes school leave-out documents for students failed to provide health records; did not adhere to contract guidelines; or failed to maintain theatre notes for sampled cases.
Others also conducted procedures and admitted students before receiving approvals, while some issued late notifications to the insurer.
In other cases, dates of admission and discharge in patients’ files were not the same as those in the NHIF system.
In one case noted in the report, one of the facilities claimed Sh40,000 for two maternity cases under Edu-Afya, instead of the Linda Mama programme.
Cases of outpatient services were also being claimed as an inpatient, in one instance leading to the loss of Sh26,000 claimed by one of the institutions.
“There were also cases of claims being made for procedures different from the ones carried out for the registered member amounting to an overpayment of Sh70,000 and Sh120,000. Another 3,855 students said to have visited hospitals for treatment could not be proved, leading to a loss of some Sh5.78 million,” it reads.
In another case, some 905 students, who are said to have visited a health facility, could not be proved for lack of supporting documents, leading to the loss of some Sh1.3 million.
This was also the case with another 22 visits, leading to the loss of another Sh33,000. “Hospital visits by another 924 students were not supported by introductory letters from the school principals or their designate.
This led to the loss of Sh924,000. Another 1,429 claims were made above contract amount of Sh1,000, leading to the overpayment of Sh741,500 and 120 amounting to Sh180,000.”
The report says that with the cases identified, it had become difficult for NHIF to verify whether it received value for money under the scheme, leading to the suspension of the said facilities.
One facility recorded the ailment of 13 students who had been circumcised as typhoid, pneumonia, severe malaria, convulsion and dysentery.
“The HCP officials amended the notifications in the system without indicating reasons for the cancellations, thus misusing the system right.”
The audit was the work of a joint standing committee between NHIF and the ministry of education. It was conducted in February for the cover period of January 2021 to December 2022.
A multi-agency team was tasked with the responsibility of investigating the said institutions following reports that a number of them were abusing the Edu-Afya programme.
Mr Nguyai told Sunday Nation that the CEO had suspended the 17 institutions without involving the board, contrary to the NHIF Act.
“I have been trying to guide the CEO. My role is to guide him on the rule of law and nobody is above the law.”
Contacted, however, Mr Kamunyo said his decision was guided by the law, adding that the suspension was part of an ongoing investigation into Edu-Afya.
“What usually happens when a violation is identified is that an institution is suspended for 90 days and then given the right of reply. And after an investigation is completed, a decision is made by the board,” he said.
“And so, the investigation of the said institutions began in April and an internal audit report was tabled on Thursday. Many facilities were investigated.”
A source on the NHIF board yesterday said the insurer lost about Sh21.2 million. The suspension, the source said, could be extended to between two and five years should the facilities be found culpable by the board.
“The law provides that any healthcare provider who commits fraud against the Fund may have their empanelment revoked and a fine of Sh500,000 levied against them. Where schools are concerned, the Ministry of Education will make a decision.”