At least Sh20 billion has been lost in the National Hospital Insurance Fund (NHIF) due to a web of manufactured claims, fake surgeries, and fraudulent activities.
Health Cabinet Secretary Susan Nakhumicha disclosed the alarming figures based on an audit conducted between January and December 2023.
Out of the 67 audited hospitals, 27 were found to be involved in fraudulent activities, leading to a loss of Sh171 million.
“Extrapolating this to the total population of 8,886 hospitals, it is estimated that approximately 3,440 might have been engaged in fraudulent activities, potentially exceeding Kes 20 billion in losses from about 40% fraudulent hospitals. Luckily 60% carry out clean business,” the CS said.
Nakhumicha said nearly Sh18 million has already been recovered.
The implicated facilities have been suspended, and efforts to recover fraudulent claims are underway.
The list of facilities involved includes instances of induced demand, particularly targeting vulnerable citizens, notably older individuals, residing in regions such as Nairobi, Meru, Nyahururu, Muranga, Kerugoya, Makueni, Tharaka Nithi, Subukia, Nanyuki, Bungoma, Chuka, and Machakos. Vulnerable patients have been enticed into unnecessary medical procedures, exploiting their susceptibility.
The investigation also revealed instances of induced sickness, where facilities deceitfully activate dormant accounts of members, financing medically unwarranted treatments.
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Fictitious records, manufactured claims, and deceptive practices, such as falsely indicating members undergoing major surgeries while actively at work, have all contributed to defrauding the NHIF.
Some hospitals have specifically targeted groups of security guards from licensed security firms, financially inducing them to provide biometrics for fraudulent purposes.
Anomalies identified include facilities conducting an exceptionally high number of eye surgeries in a day, ranging from 10 to 22, in facilities with a capacity of only 2 per day while lacking the adequate theatre capacity.
Such discrepancies raise significant doubts about the legitimacy of claims and the resources available at these facilities.
Under the EduAfya cover, healthcare facilities have been enticing healthy students, providing food incentives for their biometrics that result in high financial losses.
Cases involving nurses stationed in schools collecting biometrics of non-ill students to lodge fictitious claims have been unearthed, significantly exploiting the scheme.
In light of these revelations, the court has intervened, halting the proposed move of NHIF to the Social Health Insurance (SHI) pending further hearings.
