The Ministry of Health plans to reclassify all hospitals prior to their inclusion in the Social Health Insurance Fund (SHIF) network to eradicate fraudulent activities. This move aims to address the significant financial losses incurred by taxpayers due to fabricated claims against the National Health Insurance Fund (NHIF).
The Kenya Medical Practitioners and Dentist Council (KMPDC) will be the only body to inspect and categorise all levels of hospitals before they are contracted by SHIF.
Health PS Harry Kimtai underscored that hospitals will only be admitted into the Social Health Insurance Fund (SHIF) network after obtaining clearance from the KMPDC. Additionally, according to the new legislation, the KMPDC will be held responsible in instances of fraud.
Health CS Susan Nakhumicha told the National Assembly’s Health Committee that several hospitals contracted by the NHIF have been operating at inappropriate levels, resulting in them making claims from the fund for rates they are not eligible for.
The Health Act has six categories of hospitals, with Level One being community facilities run by certified medical clinical officers, Level Two (health facilities), Level Three (Health centres), Level Four (district hospitals), Level Five (district referral hospitals) and Level Six (national referral hospital).
According to the CS the internal audit directorate conducted investigations between July 2022 and December 2023 into 31 healthcare providers and discovered breaches of contractual obligations.
The reports have since been compiled and submitted to the audit committee of the NHIF board, but the complete board has not yet endorsed the recommendations.
“Some of the recommendations were to refund fraudulent claims paid, stop payment on claims in process and for the board to decide on the fate of the affected healthcare providers in line with clause 16.6 of the contracts, whether to suspend the healthcare providers or terminate the contract,” said Ms Nakhumicha.
She further told the committee, chaired by Endebess MP Robert Pukose, that the Attorney General had issued advice that during the transition period, the NHIF board should only deal with the winding up of the fund and not any other matter.
