MPs grill former NHIF boss over billing that costs six times more

Former NHIF chief executive officer Samson Kuhora when he appeared before the Senate Health Committee at parliament in Nairobi on October 6, 2023. [Elvis Ogina, Standard] The National Health Insurance Fund (NHIF) was taken to task by MPs to explain why it preferred a more expensive billing system. The fund is reported to prefer charging fees for service over capitation -- fee for service is whereby the insurance provider is billed after rendering service while in capitation the fee is fixed. The National Assembly Health Committee is probing eight hospitals accused of fraudulent activities in hospital claims. Former NHIF Chief Executive Samson Kuhora came under fire when he appeared before the committee. He admitted to the Robert Pukose-led committee that the fee for service was more expensive compared to capitation. "Service fee is six times more expensive compared to capitation," Kuhora told the health committee. Kuhora's response appeared to agitate the committee members who said the scheme was meant to defraud Kenyans. "Why do you make organisations go for a more expensive contract knowing it is more expensive than the other one (capitation)?" posed Pukose. National Health Insurance Fund headquarters in Upper Hill, Nairobi, on September 8, 2023. [Boniface Okendo, Standard] Samburu Woman Representative Pauline Lenguris added, "Why do you choose to go for more expensive service payers? As a committee, we recommend capitation," said Lenguris. Kuhora explained that capitation is the average cost of an outpatient visit for patients and the likelihood that a particular percentage of patients will visit a hospital. For capitation, he said, the service is paid upfront. "Capitation is more expensive for ambulances, but for outpatient it is affordable," said the former NHIF boss. Also, the committee raised concerns over reimbursement of claims by the fund to Level 2 and Level 3 hospitals. The committee noted that despite the hospitals offering basic healthcare to patients, they were receiving reimbursement running into billions of shillings compared to reimbursement to Level 4, 5 and 6 hospitals. Structurally, level 2 and 3 hospitals offer basic health care services. In the heated grilling, Nyeri Town MP Duncan Mathenge demanded an explanation on why NHIF had approved more Levels 2 and 3 for capitation. "...at levels 2 and 3...is this where fraud is mostly happening? Level 2 is purely outpatients, level 3 is maternity care," said Mathenge. The former NHIF boss did not however respond to the issue. Jekim Medical Centre is among Level 2 hospitals which were found to receive refunds running into millions of shillings from NHIF, even without patients' health records. NHIF audit also noted that the facility has been offering Edu-Afya services to students. Further, the committee took an issue with NHIF on disparities incurred in premiums offered to the National Police Service. For instance, NHIF pays Sh4.5 billion to the National Police Service annually, but utilisation is Sh6 billion. According to Kuhora, overpaying is a result of the under-costing of the premiums. "Police issue is because of under-costing. Premiums were under-costed because we utilise Sh6 billion, but pay Sh4.5 million," explained Kuhora during an interview. Eight suspended NHIF managers have been summoned to appear before the committee for grilling on Monday next week. mkahenda@standardmedia.co.ke

MPs grill former NHIF boss over billing that costs six times more

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