Massive fraud unearthed in NHIF scheme: Sh20 billion lost to fake claims

In a shocking revelation, the Ministry of Health disclosed that the National Health Insurance Fund (NHIF) scheme has suffered a staggering loss of Sh20 billion due to fraudulent activities, including manufactured claims and fake surgeries, among other schemes orchestrated by health facilities.

Health Cabinet Secretary Wafula Nakhumicha, in a Friday statement, exposed the scandal affecting health facilities across the country. Out of the 67 audited hospitals, 27 have been suspended for their involvement in the loss of Sh171 million through the NHIF program.

CS Nakhumicha disclosed that approximately 40% of the total hospitals in the country (3,440) engaged in irregular processes, resulting in substantial Sh20 billion losses. She stated, “Between January and December 2023, out of 67 audited hospitals, 27 were found to be involved in fraudulent activities, resulting in a loss of Sh171 million.”

The newly unveiled Social Health Authority (SHA) conducted an operation revealing various fraudulent activities. These activities include induced demand targeting vulnerable citizens, induced sickness with deceitful activation of dormant member accounts, and financing medically unwarranted treatments. Vulnerable groups such as the elderly were particularly targeted in areas like Nairobi, Meru, Nyahururu, Muranga, Kerugoya, Makueni, TharakaNithi, Subukia, Nanyuki, Bungoma, Chuka, and Machakos.

CS Nakhumicha highlighted instances where facilities utilized fictitious records, falsely indicating members undergoing major surgeries while actively at work. Some facilities even used security guards from licensed security firms, financially inducing them to provide biometrics for fraudulent purposes.

The ministry uncovered anomalies, including healthcare facilities enticing healthy students under the EduAfya cover and providing them with food incentives for their biometrics, resulting in significant financial losses.

Despite the widespread fraud, the ministry assured the public of efforts to restore integrity in healthcare provision. Recovery of the lost claims is underway, with Sh17.7 million recovered out of the Sh171 million lost. Several hospitals involved in fraudulent activities through the NHIF scheme have been identified, and recoveries have been initiated. These hospitals include Jekim Hospital Meru, Joy Nursing & Maternity, St. Peter’s Orthopedic and Surgical Specialty, Charity Medical Centre, and many others.