Fake surgeries the new way to milk NHIF

Fake surgeries now top the list of frauds against the National Hospital Insurance Fund (NHIF), the State agency has revealed.

The scam mainly involves healthcare providers who claim to have performed various operations and procedures during surgeries when in fact they did not, either because they were not medically necessary or because they would have resulted in reduced payment claims from the insurance fund.

The data released Thursday showed that NHIF paid Sh6.9 billion for those claims, with Sh5.6 billion going to settle major surgeries and a further Sh610 million spent on specialised surgeries. The national insurance scheme spent a further Sh667 million towards coverage of minor surgeries.

Inaccurate billing

NHIF assistant claims manager Judith Otele said most of the frauds were happening through upcoding, where healthcare providers submit inaccurate billing codes to insurance companies aiming to receive inflated reimbursements.

“The healthcare providers do this in surgeries especially. For example, a patient who walks in with a simple cut is said to have needed a tendon repair. There are also cases where a woman who had a normal delivery is upcoded to a C-section,” she said.

“Some healthcare providers bill each procedure as if it were a separate procedure just so the claims go up,” said Ms Otele.

She added that the dubious schemes are affecting patients who undergo medically unnecessary procedures.

NHIF benefits and contracting manager Gilbert Osoro said there has been a particularly sharp increase in claims and amounts in Nairobi, Central Kenya, Nyanza, and the Coast.

He said there are 80 health facilities countrywide that are under investigation for their involvement in possible fraud against NHIF while seven facilities have been suspended from offering services by the national health insurer in connection to the fraud.

“They have taken the matter to court so we cannot mention them and as for the 80 facilities we are still investigating and we would not like to blow the lid,” he said.

Medical identity theft

Ms Otele added that their investigations have also revealed that medical identity theft is rising as the new con where insurers are losing money.

“Some family names are so similar and many Kenyans use their relatives’ cards to access medical attention,” she said.

The use of technology to detect fraud and the short messages to clients when they access a health facility has, however, helped to minimise the fraud.

“We have witnessed instances where a client receives the message and they are not in the facility or have not used their cards and they come to report,” he said.

NHIF has previously admitted to losing millions through fraud.

In 2017, the insurer said that it had invited detectives from the Directorate of Criminal Investigations to probe the loss of up to Sh500 million every month through fictitious claims.

The insurer blamed the increase in fictitious claims on collusion between a section of the Fund’s unscrupulous employees and some hospitals.