80 facilities under investigation over defrauding NHIF

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An NHIF card . PHOTO COURTESY

80 health care facilities are under investigation for allegedly overstating claims, manipulation of the documents of non- existing hospitals and pharmacies against NHIF.

 Addressing a media briefing on Thursday in Nairobi, NHIF benefits and contracting manager Mr. Gilbert Osoro said that, already seven facilities have been suspended from offering services by the National health insurer in connection to possible fraud.

Some of the components of the scam include cover up and non- disclosure of medical facts at the proposal stage.

The social health insurer noted that healthcare fraud, waste, and abuse directly contributes to the need for higher premiums for sustainability and reduces the amount of money available to improve quality of care for beneficiaries.

Osoro pointed out that, this has led to the shrinking of the available benefit package to members, thereby raising barriers to assessing health while distorting equity in the financing scheme.

“Fraud leads to the shrinking of the available benefit package to members, thereby raising barriers to accessing quality health and ultimately increasing the cost of healthcare,” said Mr. Osoro.

 “NHIF management has taken note of the increase in the magnitude of the risk by re-engineering the claims process to enhance efficiency and effectiveness in payment processing for legitimate claimants,”Osoro added

He said to curb likely fraud; NHIF will invest money in new futuristic technology that allows for review, Investigations and timely payments of the claims.

The system will replace the earlier approach referred to as pay-and-chase for recovery of payments which had loopholes for possible fraud and abuse.

More than half of the insurance fund in Kenya is perpetrated in the medical and motor insurance sectors.

A report by advisory firm KPMG released recently estimates that 25 percent of health claims made in Kenya are fraudulent.

 In 2016, the sector paid out sh. 1.9 billion in medical claims, meaning insurance firms may have lost up to sh. 500 million to fraudsters.

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