At least 20 hospitals have been blacklisted for unethical practices, exposing the dubious methods used by the health facilities to defraud the multibillion-shilling teachers’ medical scheme.
Teachers and their dependents have also come under scrutiny after it was revealed that they conspired with hospitals to defraud the Teachers Service Commission (TSC) of insurance coverage. Making false claims, overcharging members, listing false ailments, and impersonation are among the vices.
According to a brief prepared by Minet Kenya, the firm hired by TSC to manage the scheme, there are at least ten ways for teachers, their dependents, and hospitals to take advantage of the scheme.
They include impersonation, billing for services not rendered, billing for conditions not covered by the scheme, double billing of medical expenses, and falsifying patient hospital stay duration.
Incorrect reporting of diagnoses or procedures, false and unnecessary drug prescriptions, abnormal service utilization, bribery, and unethical inducement are all ways to cheat.
In addition, Minet Kenya Chief Executive Sammy Muthui stated that many facilities have been blacklisted and others are currently being investigated for violating the seven-day rule.
Muthui stated that under this rule, if a patient is treated for a condition and then returns to the hospital within seven days to be treated for the same ailment, they should not be charged.
However, there have been instances where this rule has been broken and patients have been asked to pay or turned away.” This is a fraud, and we take it seriously;’ Muthui said.
According to the capitation agreement signed by AON Mi net with the service providers, health facilities are required to provide quality services to all teachers without requiring a return to the hospital for primary healthcare, unless for a different diagnosis or complication.
In fact, hospitals are not even supposed to discuss the seven-day rule according to Muthui. “We have had to blacklist many facilities for this misbehaviour:’ He said.
There are 607 medical service providers who can be accessed directly or through referral. Muthui, on the other hand, claims that the fraud has only been discovered in a small percentage of the health facilities contracted to treat teachers and their dependents.
A small number of service providers are currently under investigation, as disciplinary action against them will follow due to the poor services that Muthui says are not impressive under the scheme.
MINET To Start Rating Hospital Services
TSC Chief Executive Officer Nancy Macharia stated that the teachers’ coverage is 99.9% effective and requested that Minet close existing gaps. Muthui stated that they have begun a new system of rating hospitals listed under the scheme, and that those with low scores will be removed from the list.
He did, however, say that impersonation is still one of the unethical ways that both teachers and medical facilities take advantage of 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. Muthu I added that in most cases, hospitals and teachers work together to facilitate impersonation.
About six patients who are not members of the scheme have already been identified and investigations are ongoing.
He claimed that male teachers had been caught taking members of their second family to benefit from the scheme in violation of the rules. Muthui claims that in the majority of cases, teachers use their identity aassist relatives such as parents, siblings, or unregistered spouses with the same names.
Teachers impersonate students in order to obtain maternity leave. In most cases, the person on the bed is not the person on the scheme rolI.
“For teachers who are caught in this malpractice we pass them over to TSC for the disciplinary procedure;’ he added. It was also discovered that some hospitals make exorbitant claims based on false diagnoses, while others present bills for members who were admitted.
In other cases, healthcare facilities demand payment for patients who are not even being treated.
“Other facilities also cheat on the number of days patients were admitted,” said Muthui. Some hospitals also file claims for services that are not covered by the medical plan. They (hospitals) create bills and forward them for payment.