Teachers medical cover to change due to fraud

A major shake up of the Sh6 billion teachers' medical scheme is underway following complaints of poor services lodged by the beneficiaries.

The Standard has established that more than 200 medical service providers have been blacklisted and will be struck off the roll on grounds of fraud.

It has emerged that AON – the scheme administrator – has vetted all the 1,600 hospitals that were contracted to take care of the 305,000 teachers across the country.

The one-year contract expires tomorrow but reports indicate that following many complaints of poor services, non-compliance, and fraud, more hospitals will be blacklisted.

The Teachers Service Commission (TSC) contracted AON on July 1, 2015, to manage the multi-billion shilling medical scheme.

The scheme, renewed last year, now takes care of 700,000 beneficiaries.

AON yesterday admitted that there were challenges and pointed a finger at rogue hospitals.

“It is true we have had challenges but we are saying that we are taking firm action that will guarantee all teachers better service delivery,” reads the statement.

The document says that only hospitals that will commit to serve teachers better and within the terms of the contract will be considered in order to end fraud.

A letter by a teachers' union to TSC asks the teachers employer to intervene.

“It has come to our attention that teachers are turned away from health facilities citing lack of payment by the insurance provider,” said Akelo Misori, the Kenya Union of Post Primary Teachers Union (Kuppet) secretary general.

“This has forced teachers to pay for health services in spite of their medical allowance having been deducted under the comprehensive medical scheme cover,” said Misori in the letter dated September 28.

The letter is addressed to the TSC chief executive officer, Nancy Macharia, and copied to AON.

AON Chief Executive Officer Sammy Muthui yesterday said the money issue had been resolved.

“The Government has released money and we shall honour our obligation,” said Mr Muthui.

The complaints include hospitals not having adequate facilities and poor infrastructure to recognise and authorise treatment for teachers and their dependants.

Teachers have also complained of non-payment of bills to hospitals, closure of county offices, and failure to have staff to handle their complaints.

Muthui, however, said: “We want to state that we are weeding out non-compliant service providers to retain a professional list that will give teachers value for their money.”

Crude ways

It emerged yesterday that the blacklisted hospitals have devised crude ways of defrauding the teachers’ medical scheme.

A status report seen by The Standard shows that fraud, misuse and overuse of the cover, and false claims are some of the ways hospitals use to steal scheme money.

The document cites cases where hospitals demand payment for services not delivered.

A hospital in the Coast region made claims for nine patients who were not admitted to the facility.