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NHIF loses Ksh.20b through fake claims as CS Nakhumicha suspends 27 hospitals 

CS Nakhumicha suspends 27 hospitals found involved in fraudulent activities that resulted in loss of Ksh.20b NHIF funds.

The National Health Insurance Fund (NHIF) program has lost Ksh.20 billion, according to the Ministry of Health, as a result of false claims, phony procedures, and other dishonest actions by medical facilities.

In a statement released on Friday, Health Cabinet Secretary Wafula Nakhumicha revealed the full extent of the fraud involving healthcare facilities. 

She stated that 27 of the 67 audited hospitals in the nation had been suspended due to Ksh. 171 million in losses incurred under the NHIF program.

According to CS Nakhumicha, irregular processes at 3,440 hospitals, or almost 40% of all hospitals in the nation, caused losses of Ksh.20 billion.

“Between January and December 2023, out of 67 audited hospitals, 27 were found to be involved in fraudulent activities, resulting in a loss of Ksh.171 million,” she stated.

“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 Ksh.20 billion in losses from about 40% fraudulent hospitals. Luckily 60% carry out clean business.”

In the operation carried out by the newly unveiled Social Health Authority (SHA), the CS cited fraudulent activities including instances of induced demand targeting vulnerable citizens such as the elderly, induced sickness where facilities would deceitfully activate dormant member accounts, as well as financing medically unwarranted treatments. 

According to CS Nakhumicha, the facilities enticed patients into unnecessary medical procedures, especially in Nairobi, Meru, Nyahururu, Muranga, Kerugoya, Makueni, Tharaka Nithi, Subukia, Nanyuki, Bungoma, Chuka, and Machakos.

“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 Fund,” she stated.

The Health CS observed that some hospitals targeted groups of security guards from licensed security firms, financially inducing them to provide biometrics for fraudulent purposes.

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Nakhmicha also pointed out that the ministry identified anomalies where facilities were conducting an exceptionally high number of eye surgeries in a day, ranging from 10 to 22 while their capacity allows them to conduct two surgeries in a day.

She further mentioned that the healthcare facilities have been enticing healthy students, under the EduAfya cover providing food incentives for their biometrics.

“Additionally, cases involving nurses stationed in schools collecting biometrics of non-ill students to lodge fictitious claims have been unearthed, significantly exploiting the scheme,” CS Nakhumicha added.

The hospitals include; Jekim Hospital -Nkubu Ltd, Jekim Medical Centre, Joy Nursing & Maternity, Amal Hospital Ltd, Beirut Pharmacy and Medical Centre, St. Peter’s Orthopedic and Surgical Specialty, Afya Bora Hospital Annex Ltd in Mwea, Charity Medical Centre, Queens and Kings Hospital, Chest & Skin Clinic and Kiritiri Medical Healthcare.

Others are Meswo (Tunza) Medical Services, Familia Bora Medical, Naivasha Quality Healthcare, Bingwa Family Clinic, Elburgon Nursing Home, Nyamira Jamii Medical, St. Joseph Shelter of Hope, Lenmek Hospital, Equity Afia Buruburu, Muranga High School Dispensary, Mathingira Medical Centre, Ruai Medical Centre and Thuti Medical Clinic.

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