Key services now require NHIF approval

Hospitals will now have to send a pre-authorisation request for specialised services to the national health insurer through an online platform rolled out to curb fraud, before conducting any procedure on a patient.

National Hospital Insurance Fund chief executive officer Geoffrey Mwangi said this will help the NHIF in dealing with rising cases of fraudulent claims.


On Monday, Mr Mwangi clarified that the NHIF had not stopped paying any hospital for bills claimed, but was only tightening the checks to curb fraud.

“I wonder why some hospitals are saying we have suspended paying for key services such as MRI (magnetic resonance imaging) and CT (computed tomography) scan,” Mr Mwangi said.

“There is no way we can stop giving services to our members who remit their money every month. The problem is with hospitals and not patients. We are taking these measures to ensure order.”

He accused some hospitals of not wanting to follow the insurer’s protocols.

“There are small and medium-sized private hospitals that were offering the services and conning the insurer of funds.

“Now that they have noticed that we have to approve before a service is delivered, they are afraid that we will get hold of them,” Mr Mwangi told the Nation on phone.

According to the insurer, MRI and CT scans were some of the services that had opened floodgates for fake claims.

“We are going to take legal action against all the facilities that have been stealing from us. Tomorrow, we will publish names of all the facilities involved in the fraud,” said Mr Mwangi.

The NHIF has recently improved its payouts to hospitals as it recruits more members to the medical aid scheme.

According to Mr Mwangi, some hospitals have been offering a service that is cheap, only to claim that it had provided one that is expensive.

The demand for letters could bring in some element of bureaucracy, which patients may dislike, but Mr Mwangi said the idea is to smoothen any transactions.

“I know it will take time before they get used to the system but with time, everything will be fine. We are going to register more members and even increase the number of benefits,” he said.

The national health insurer covers MRI up to a maximum of Sh15,000 per session.

The additional expenditures increased the total sum to Sh4 billion.

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