Fake Surgeries Used to Defraud NHIF of Billions

National Hospital Insurance Fund (NHIF) officials have exposed a new method used by healthcare providers to swindle billions of shillings.

According to Business Daily, fake surgeries top the list of frauds against NHIF.

The scam involves healthcare providers who allege to have performed various operations and procedures during surgeries when in fact they did not.

NHIF assistant claims manager Judith Otele mentioned that most of the frauds happened through upcoding where healthcare providers submit inaccurate billing codes in a bid to receive inflated reimbursements.

“Some healthcare providers bill each procedure as if it were a separate procedure just so the claims go up,” she mentioned.

Otele further revealed that the dubious scheme was affecting patients who undergo medically unnecessary procedures.

Data released by the state agency, on Thursday, for major, minor and specialised surgeries tripled last year with 81,571 recorded in 2017/18 from 24,496 in the previous year.

NHIF paid Ksh6.9 billion for the claims with the majority of the cash used to settle major surgeries.
Areas most affected include Nairobi, Central Kenya, Nyanza and the Coast.

They are 80 facilities countrywide that are under investigation for involvement in the scheme.

Seven facilities have been suspended from offering services by NHIF in connection with the fraud.

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