The National Health Insurance Fund (NHIF) claimed it paid out Kes.368 million in excess claims due to typing errors and cannot trace where the funds went.
Auditor-General Nancy Gathungu exposed leakages within the Fund, revealing that in the year to June 2023, NHIF paid Kes.814.9 million in claims, while hospitals only billed Kes.447.12 million through some 10 schemes.
The NHIF attributed the excess payment to “typing errors” by hospital clerks but could not provide proof of having recovered the excess payments or requested hospitals to reconcile the data, according to Ms. Gathungu.
“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,” Ms Gathungu said in her report.
The audit further reveals that in the year to June 2023, different hospitals billed NHIF Kes.37.1 million under the Linda Mama scheme, but the Fund paid out Kes.91.6 million, resulting in Kes.54.5 million in excess payments.
In total, NHIF reported paying claims totaling Kes.4.1 billion for the Linda Mama Programme, which supports free child delivery for all women in the country.
The audit highlighted potential fraud within the programme, including numerous cases of multiple duplications.
“The amount includes Sh5,713,000 paid to NHIF accredited hospitals for 656 duplicate 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 indicates.
The audit exposes significant instances of duplications and excess payments under the National Health Scheme (NHS). In one case, while hospitals billed the Fund Kes.280.6 million through the NHS Scheme, the NHIF paid Kes.486.6 million, resulting in an unexplained excess of Kes.205.9 million.
Additionally, the audit exposes that out of a Kes.12 billion debt owed to healthcare providers, Kes.2.9 billion included “duplicated healthcare providers with the same name but different outstanding amounts and different hospital codes.”
These excess payments and duplications in claim payments were among the loopholes flagged by Auditor-General Nancy Gathungu, highlighting the mismanagement within the NHIF.
The audit also flagged cases where hospitals raised claims five years after the 30-day submission period had lapsed.
