At least 20 hospitals have been blacklisted for engaging in unethical practices, exposing dubious ways the health facilities use to defraud the multibillion-shilling teachers’ medical scheme.
Teachers and their dependents have also come into sharp focus as it has been revealed that they collude with hospitals to fleece the Teachers Service Commission (TSC) of the insurance cover.
The vices range from making fake claims, overcharging members, listing fake ailments to impersonation.
A brief by Minet Kenya, the firm contracted by TSC to manage the scheme, listed at least 10 ways that teachers, their dependents and hospitals use to fleece the scheme.
They include impersonation, billing for services not rendered, billing for conditions not covered under the scheme, double billing of medical expenses and falsification of the length of stay of patients in hospitals.
Incorrect reporting of diagnosis or procedures, false and unnecessary prescription of drugs, abnormal utilisation of services, bribery and unethical inducement are also ways used to cheat.
In addition to these, Minet Kenya Chief Executive Sammy Muthui said many facilities have been blacklisted and others presently put under investigations for abusing the seven-day rule.
Under this rule, Muthui said if a patient is treated for a condition and within seven days returns to the hospital to be cared for over the same ailment, they should not be charged.
“The member should never be asked to pay out of pocket. But we have had cases where this rule has been breached and patients asked to pay money or turned away. This is fraud and we take it seriously,” he said.
Muthui said as per the capitation agreement they signed with the service providers, health facilities are required to provide quality services to all the teachers without warranting a return to the hospital for primary healthcare, unless for a different diagnosis or a complication.
“In fact, hospitals are not supposed to even discuss the seven-day rule. They are just required to offer services as per the agreement. But we have had to blacklist many facilities for this misbehaviour,” said Muthui.
There are 607 medical service providers available on both direct and referral access.
Muthui, however, said the fraud has been detected in just a small fraction of the health facilities contracted to treat teachers and their dependents.
“We have a small number of service providers that we are already investigating and we are taking disciplinary action against them because they provide poor services that are not impressive under the scheme,” he said.
TSC Chief Executive Officer Nancy Macharia said the teachers’ cover is 99.9 per cent effective and asked Minet to tighten existing gaps.
“It is just a small fraction that gives us sleepless nights. And I can assure you that we are very hard on Minet to ensure teachers are happy,” said Macharia.
Muthui said they have embarked on a new system of rating hospitals listed under the scheme and noted that those that will post poor scores will be struck off the roll.
“We pick facilities that are accredited by the government, but it is emerging that somewhere along the way some of them start to provide dismal services,” he said.
He however said impersonation remains one of the unethical ways both teachers and medical facilities exploit the scheme.
“We are talking about public funds and we have a duty to care. We have a legal and investigations department dealing with these. As we speak, many cases are under investigation and dozen others in court,” said Muthui.
He explained that in most cases, hospitals collude with teachers to abet impersonation.
“As we speak we have about six IVF patients who are not scheme members. This is an expensive treatment and we are presently carrying out investigations,” said Muthui.
He said male teachers have been caught taking members of their second family to benefit from the scheme against the laid down rules.
Muthui said in most cases, teachers use their identity to help their relatives such as parents, siblings, or unregistered spouses.
“In our African setup and tradition, your cousin may have a similar name as yours. Your niece or nephew may have the same name as your children. So they use the same name to get treatment from hospitals,” said Muthui.
“When the preauthorisation team comes, they find a totally different person from the listed beneficiary on the hospital bed.”
Impersonation is also done by teachers to cheat maternity cover. “In most cases, you find the person who is on the bed is not the one on the scheme roll,” said Muthui.
“For teachers who are caught in this malpractice we pass them over to TSC for the disciplinary procedure,” he added.
It also emerged that some hospitals make huge claims based on false diagnoses while others presented bills for members who were never admitted.
In other cases, the health facilities demand payment for patients not even treated.
“Other facilities also cheat on the number of days patients were admitted,” said Muthui.
Some hospitals also make claims on services not covered under the medical scheme. “They (hospitals) manufacture bills and forward them for payments,” said Muthui.
He said in the past, the scheme administrator has had cases where some hospitals made claims for gynaecological and maternity services offered for male members of the scheme.
Cases of bribery have also been reported among teachers and hospitals.
“We have had cases where hospitals bribed scheme members or members’ representatives to cover up false claims and other corrupt practices,” said Muthui.
“In one such case, a patient confirmed that no breast ultrasound or excision was carried out, yet the two services were included in the final bills.”