The National Hospital Insurance Fund (NHIF) has stopped settling diagnostic test bills from hundreds of private service providers it accuses of making fraudulent claims.
NHIF said the decision was informed by the realization that the facilities have been making claims for services not rendered, thereby raising the level of fraudulent claims in the fund.
It said Thursday that it had suspended paying for diagnostics tests such as MRI and CT-scan at hundreds of small and medium-sized private facilities whose list it plans to publish in the coming weeks.
“We have suspended the programme with these hospitals since they are fraudsters,” said NHIF CEO Geoffrey Mwangi, adding that a full list bearing the names of the culpable facilities would soon be published. “We had to look for a way to stop this daylight thievery.”
NHIF said it had taken legal action against some of the service providers such as Nairobi-based German Medical Centre.
Members can, however, access the diagnostic tests at reputable private hospitals such as Aga Khan, Nairobi and MP Shah under the NHIF outpatient scheme.
To access the service, patients must obtain a pre-authorisation letter from the hospital, which will be sent to NHIF for approval.
The NHIF covers MRIs up to a maximum of Sh15,000 per session while settlement of CT-scans are capped at Sh8,000.
The national health insurer has recently announced an increase in fraud cases, including billings for major surgeries where only minor procedures have been done.
The number of medical procedures done for members have also been multiplied many times to increase amounts payable for claims.
But it’s the MRI and CT-scans that have opened floodgates for fake claims, prompting the clampdown on small service providers.
The NHIF in 2015 introduced outpatient cover and enhanced benefits for chronic ailments such as cancer and kidney dialysis.
This came after it raised the amount that workers contribute to the fund from Sh320 to a graduated scale of between Sh500 and Sh1,700 per month based on their pay scale.
The public insurer raised Sh23.7 billion in revenues in the six months to December and paid Sh17.1 billion in claims, translating to a surplus of Sh2.2 billion after deducting operation costs.
The enhanced cover came as a big relief for low-income households that were unable to access treatment for chronic diseases in private hospitals.
Under the outpatient scheme, the national health insurer pays Sh1,200 annually to a facility that the contributor and his family has chosen and where they are entitled to services without cost limits.