Health Cabinet Secretary Aden Duale has presided over the inauguration of the National Health Insurance Fund (NHIF) Pending Medical Claims Verification Committee at Afya House, Nairobi.
Last month, President William Ruto directed the government to pay all hospitals with total claims of Ksh 10 million and below in full, representing 91pc of all facilities that were contracted by NHIF.
The remaining 9pc of hospitals with total claims of above Ksh. 10 million, will be subjected to a verification exercise to be completed within 90 days after which a payment plan will be agreed upon.
To this end, the Committee was established so as to provide an independent, thorough, and transparent review of medical claims submitted to the defunct NHIF which to date, remain unpaid.
According to CS Duale, the available records indicate that the defunct NHIF owes Health Care Providers approximately Kshs. 33 billion.
The Committee which will serve for a period of three months has been urged to thoroughly scrutinize the outstanding claims and only recommend the genuine claims for payment.
“Whilst the Government appreciates the financial difficulties being faced by some of these health care providers, it is important that this process is undertaken to guarantee not only value for money but also transparency and accountability in the purchase of health care services.” Noted Duale.
The Committee is mandated to scrutinize and verify the authenticity of all pending medical claims and establish a clearly defined criteria and robust framework for detailed claims examination and analysis of such pending medical claims with a view to determining the genuineness of each or otherwise.
Similarly, the Committee will also be expected to identify and recommend actions on any fraudulent, false, or exaggerated claims and also identify any cases where there may have been corrupt, fraudulent and false medical claims and make appropriate recommendations to the relevant Government Agencies.
It should also make recommendations to the Ministry of Health on the necessary actions to be taken for satisfactory disposal or settlement of the identified pending medical claims as well as propose reforms or measures that will ensure/ prevent the recurrence of unverified or accumulated claims in the future.
According to CS Duale, members of the Committee which will be chaired by James Masiro Ojee and deputized by Dr. Anne Wamae shall serve for a period of three months from the date of the Gazette Notice which was 28th March 2025.
He said government has taken this step to restore public trust, accountability and transparency in the financing of healthcare system in Kenya.
The CS listed some of the areas the Committee should focus on which included: Some facilities reportedly offered services without valid contracts or outside the scope of their contracts, while some facilities offered services beyond the hospital level/capacity.
Duale also wants the Committee to probe doctors claiming against services outside their areas of specialization, exaggerated invoices/ billings that are beyond the applicable tariffs, reported cases of manipulation of member records and their dependants, unwarranted admissions/prolonged stay in the hospital, unsupported surgeries, lack of notifications of claims, reported claims by non-existent facilities, duplicated claims as well as manipulation of the system information and records.
