NHIF may lose authority to review, pay hospital claims

The National Hospital Insurance Fund (NHIF) may not review and pay claims to hospitals if the findings of the new reforms aimed at delivering Universal Health Coverage (UHC) by 2022 are tabled in June, the Sunday Nation has learnt.

This follows complaints that most corruption cases rise from reviewing and payments of claims and hospitals colluding with the fund to generate false medical bills for people who have not sought treatment.

OBJECTIVITY

Some of the NHIF officials are said to have pocketed up to Sh12 billion from beneficiaries who had not sought medical treatment.

“These are some of the areas we are looking at and asking ourselves whether they should be the people doing the reviews or should another body be contracted to pay out claims to hospitals,” said Mr James Wambugu, chairperson reforms team.

The Health Financial Expert Panel on Transformation and Repositioning of NHIF as a strategic purchaser of health services for the attainment of UHC by 2022 while briefing the media said they will also ensure that systems are put in place to seal the loopholes that are exploited by some of the officials.

Currently, after hospitals attend to patients, the claims are sent to NHIF for review and then the hospitals are paid.

“What we are looking at is whether they have the capacity of reviewing the claims and doing the payout. We must separate the roles for objectivity in the process,” he said.

He said lack of institutional capacity, on what roles need to be played and who plays them has been a major problem.

“There is no differentiation on what roles need to be played and by who and which ones need to be separated. We are working on it and the results should be ready sometime in June,” he said.

He adds: “We look at the qualifications of the people performing the roles, then with this we are going to move away from where we rely on NHIF as an individual to different individuals counterchecking each other.”

COMMON KENYANS

Considering that bigger percentage of claim pay-outs goes to private facilities and the current beneficiaries of the fund are largely people in the formal sector who choose which hospitals to go to, the team is looking at ways of bringing in the common Kenyan.

Mr Wambugu said that with UHC, the government will have a framework on taking care of everyone focusing mostly on Wanjiku.

Currently, NHIF covers about 20 per cent of the population while 80 per cent are in other insurances.

Principal contributors to the NHIF have hit 6.5 million following a campaign that recruited new members from the informal sector.

“There is a big percentage of Kenyans without risk management framework for their health services, the intention is to make sure they are brought under the umbrella of NHIF so that they can also benefit,” he said

ACCREDITING

Earlier, the ministry of health had scrapped the mandate of accrediting the health facilities from the fund.

The Health Ministry and the Medical Practitioners and Dentists Board will be the accrediting agencies. After accreditation, hospitals will be gazetted and the insurance provider will pick it up.

“NHIF will move away from issues that are peripheral to it. The Ministry of Health and the board will carry out the work,” said the Health Cabinet Secretary Sicily Kariuki

She adds: “When the two new agencies take over, they will monitor payments to hospitals, assess the quality of services Kenyans are getting and the competencies of the facilities.”

The agencies will also be in charge of strengthening pharmaceutical practices and regulatory systems.

The independent panel of experts with 17 members will be required to develop an action plan that will see the transformation of NHIF into a strategic purchaser of health services.