The national insurer is warning rogue private hospitals denying paid up members' services against misleading the patients.
In a number of complaints received by the Nation. Africa it has emerged that some hospitals are turning away patients, claiming that the National Health Insurance Fund (NHIF) has not rendered payments. Others are being told that the earliest they can get services in some of the hospitals is July 1.
Mr Emmanuel Juma went to one of the private hospitals on the outskirts of Nairobi and was told that he could only use the card for inpatient services but not outpatient, since the insurer was not remitting money to the hospital.
"I was feeling a bit weak yesterday (Wednesday), went to a hospital in Kitengela just for the normal check-up but was told I could not use my card for outpatient services because NHIF had not paid the hospital," he said.
He was told the earliest he could use his card was July 1.
"I am a paid up member, the whole of this year, I have paid for my subscription, why on earth would they dictate at what point I get the services, this is so unfair. What happens if one does not have other medical insurance and they depend fully on the NHIF card and they are unwell?" asked Mr Juma.
Private insurer card
As for Ms Elizabeth Mutindwa, this has been happening for the past two months.
"I have arthritis and because of the cold weather, I experience pain and I was just going for a check-up, I cannot use my NHIF card, my employer deducts my money every month to pay NHIF, why can't I get the services?" she asked.
She continues: "I am very fortunate that if they refuse to use my NHIF card, I can use my private insurer card. What happens to people in the village who struggle to get Sh500 for them to pay their monthly subscription and when they are unwell they can't get the services?"
These are not exclusive cases, the national insurer card holders and paid up members have been complaining of numerous scenarios where they have been turned away by hospitals yet they are paid up members.
However, according to the NHIF chief executive Peter Kamunyo, all paid up members should get services in accredited hospitals and that no one should be turned away.
"We have not released any circular that hospitals should suspend services until July 1, if anything, we normally communicate to facilities through writing. This is strange and we are going to investigate," Dr Kamunyo said.
He said currently, the fund is doing e-claim installation and some hospitals do not meet the criteria and lack a valid licence to practice.
"For those who do not meet the criteria, we normally suspend them until they comply and am suspecting that the said hospitals have issues with the system and that's why they are turning away patients," he said.
He continues: "If a facility refuses to offer services, then launch a complaint and we shall pick it up," Dr Kamunyo advised.
The NHIF started digitising its operations to curb fraud and only pay genuine claims. This locked out rogue hospitals that have been minting money through dubious claims.
In a Bill yet to be discussed before the Parliament, the insurer will only pay hospital bills after patients have exhausted the limit from private insurers. The government-backed NHIF (Amendment) Bill 2021 introduced in Parliament, wants the insurer to only step in as a last resort for contributors who also have private covers.
The proposal is a shift from the current practice where NHIF makes the first payment, usually a small portion of the total bill, leaving the rest to private insurers.
"Where a beneficiary has a private health insurance cover, the private health insurance shall be liable for payment up to the limits the beneficiary is covered," reads the Bill. The Fund (NHIF) shall cover the outstanding bill where private insurance cover's limits have been exhausted subject to the Fund's applicable limits."