NHIF: ‘Typing errors’ caused Sh368m loss in claim payouts
The National Health Insurance Fund (NHIF) building in Nairobi on June 5, 2024.
The National Health Insurance Fund (NHIF) has claimed that it paid out Sh368 million in excess claims due to "typing errors" and has no proof of where the money went.
In a scandal exposing leakages within the fund managing billions of shillings belonging to Kenyans, Auditor-General Nancy Gathungu reveals that in the year to June 2023, NHIF paid Sh814.9million claims yet hospitals only billed Sh447.12 million through some 10 schemes.
The NHIF then blamed the excess payment on “typing errors” by hospital clerks, but could not provide proof of either having recovered the excess payments or asked the hospitals to reconcile the data, the auditor-general reveals.
“Review of payment data revealed that the hospitals billed Sh447,122,141 against claims paid amounting to Sh814,893,467 resulting to unexplained variance of Sh367,771,326. Although management attributed the variance to typing errors made by hospital clerks while inputting bill amounts in the e-claim system, there was no evidence of reconciling the billed amount to claims paid or requests for refunds for overpayments,” Ms Gathungu said in her report.
The audit reveals that in the year to June 2023, out of Sh37.1 million that different hospitals billed the Fund with regards to the Linda Mama scheme, NHIF paid Sh91.6 million (Sh54.5 million in excess).
In total, the NHIF reported paying claims totaling Sh4.1 billion relating to Linda Mama Programme, which supports free child delivery for all women in the country.
The audit notes that claims relating to the programme were filled with possible cases of fraud, including instances of multiple duplications.
“The amount includes Sh5,713,000 paid to NHIF accredited hospitals whose analysis revealed 656 duplicate case code (01) on caesarean section delivery procedures carried out on the same patient. Similarly, the amount includes a balance of Sh41,332,700 whose analysis revealed 10,860 duplicated case code (02) on normal deliveries on the same patient,” the audit notes.
Under the National Health Scheme (NHS) the audit also exposes instances of duplications and excess payments. In one instance while hospitals billed the Fund Sh280.6 million through the NHS Scheme, the NHIF paid Sh486.6 million (an excess of Sh205.9 million that the Fund did not explain).
“Analysis of claims payment schedules revealed an amount of Sh247,021,907 on duplicate payment of claims in respect to NHS at Sh221,448,407 and Indigent’ Sponsorship (GOK) Program at Sh25,573,500,” the audit notes.
The audit also exposes that out of a Sh12 billion debt owed to healthcare providers, Sh2.9 billion was found to contain “duplicated healthcare providers with the same name but different outstanding amounts and different hospital codes.”
The excess payments and duplications in claim payments were just part of the loopholes Ms Gathungu flagged in the management of the NHIF, which exposed it to loss of billions of shillings, even as patients relying on its cover continue to suffer poor services and denial of services in some instances.
The audit also flags instances where hospitals are raising claims with NHIF up to five years after lapse of the 30-day period, within which health facilities must submit claims.
Quality assurance
It also notes that the Fund operates with very low numbers of quality assurance officers to effectively monitor patient admissions and ensure health facilities don’t raise fictitious claims, which could be exposing it to claims worth billions of shillings that should have been avoided.
“Review of human resource records revealed that 23 branch managers and 29 quality assurance officers who are key personnel in the management of claims have been in the same branch for between 5-13 years. This may result in familiarity or friendly approach to clients which is likely to compromise surveillance and enforcement duties,” the audit notes.
