At least 20 more 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.”
AON MINET BENEFIT STRUCTURE FOR TEACHERS
Below are benefits teachers get from the AON Minet cover.
|Job Group||Outpatient||Inpatient||Dental||Optical||Maternity||Group life||Last Expense||International Referral||International Travel|
This is treatment which requires admission in a hospital or day care surgery/procedure. The benefits (paid net of NHIF rebates) under this cover include but are not limited to:
• Bed entitlement.
• Doctor’s Fees (Physician, Surgeon & Anesthetist fee).
• ICU/HDU/Critical care and theatre Charges.
• Drugs/Medicines, dressings and internal surgical appliance.
• X-ray, ultrasound, ECG, Computerized Tomography Scans (CT Scans) and MRI Scans.
• Radiotherapy and Chemotherapy.
• In-Patient Physiotherapy & Hydrotherapy.
• Occupational therapy.
• Hospital accommodation for accompanying parent and /or guardian for hospitalised children below seven (7) years.
• Medical Emergency Road evacuation services leading to admission.
• Congenital defects/genetic disorders.
• Post- Hospitalisation benefit of up to two (2) weeks for other sicknesses and six (6) weeks for accident cases after discharge.
• Day care Surgery for minor surgical treatment that may not require admission.
• In-vitro Fertilisation (IVF).
• Renal dialysis.
• Cancer Treatment and related procedures and tests.
• Medical education.
• Chronic Disease Management.
This is treatment that does not require admission or daycare surgery in a hospital. The outpatient cover caters for all routine outpatient services which include but are not limited to:
• Routine outpatient consultations.
• Prescribed Diagnostic Laboratory and Radiology services (X- ray, ultra sound, MRI and CT Scans).
• Prescribed physiotherapy.
• Prescribed drugs and dressing.
• Referral Outpatient to specialists.
• HIV/AIDS related conditions and prescribed ARV’s to the full cover limit per family per annum.
• Routine Immunizations: KEPI Vaccinations, Baby Friendly Vaccines.
• Newly diagnosed chronic conditions.
• Pre-existing chronic conditions (including cancer).
• Pap smear for ladies and PSA for men- (for principal members only).
• Medical Emergency Road ambulance evacuation services.
• Rehabilitation services as per limits.
• Preventive care: free Medical camps, Mobile Clinics for events, counselling on lifestyle and wellness.
• Prescribed preventive and curative drugs/care (Including pressure stockings and clinical corset belt).
The benefits under this cover include but are not limited to:
• Routine antenatal check-up.
• Delivery/ Doctors Fees.
• Postnatal care up to six (6) weeks post-delivery.
• Routine Immunisations (KEPI) and Baby Friendly Vaccines.
• 1st emergency caesarean section, subsequent elective CS and normal delivery.
• Pre-maturity/Pre-term upto 37 weeks.
• Congenital conditions.
NB: The maternity benefit is available to principal members and/or their spouse only.
The benefits under this cover include but are not limited to:
• Dental Consultation and Anaesthetist’s fees.
• Dental X-rays and Root canal treatment.
• Tooth Extraction.
• Deformation surgery.
• Scaling necessitated by a prevailing medical condition and prescribed by a dentist.
• Dentures necessitated by an accident/ injury.
This benefit caters for expenses related to eye treatment which includes but not limited to:
• Cost of frames – members who have obtained frames will not be entitled to a replacement within one year.
• Cost of lenses – Not entitled to a replacement within one year unless necessitated by a medical condition or change in prescription by an ophthalmologist.
• Prescription for ophthalmic treatment and eye lenses.
• Ophthalmic ultrasound if prescribed by the Ophthalmologist.
GROUP LIFE BENEFIT
This benefit is payable to the next of kin upon the demise of a principal member. To access the group life benefit, the following information should be availed to Minet at the earliest possible convenience:
• The death certificate- original or a certified copy.
• The burial permit- original or a certified copy.
• Surrender of ID form (original or a certified copy) / ID copy of the deceased.
• A copy of the Next of Kin’s ID.
• A copy of the ATM card or bank statement of the claimant (Next of Kin) indicating the account number, the account name, the bank and the branch where the account was opened.
NB: *Payment will be made to a valid account number held in a registered commercial bank.
LAST EXPENSE BENEFIT
This benefit is payable to the next of kin upon the demise of a principal member mainly to cater for funeral expenses. It is payable within 48 hours subject to confirmation of the Next of Kin and upon provision of the following documents:
• The full name of the deceased.
• The TSC Number.
• The Burial Permit indicating date of death.
• The next of kin details (Name, Relationship to Deceased, Phone Number).
• A copy of the ATM card or bank statement (of Next of Kin) indicating the account number, the account name, the bank and the branch where the account was opened.
Chief’s letter in case the deceased had not declared their next of kin.
NB: * Submission of Group Life and Last Expense Claims must be done within 12 months after which it will not be payable.
Psychiatric and Counselling Services
Provision of Psycho-social support programs for employees for conditions such as chemical dependency, stress, post-traumatic counselling, relationship difficulties, anxiety and depression, parenting, legal or financial distress etc. services will include but not limited to:
• Psychiatric and tele-counselling through the Minet toll free line 0800720029 available 24 hours a day, 7 days a week.
• Onsite counselling services in some special instances.
• Referrals to face to face counselling by a specialist in some special instances.
Expenses for the following will not be covered under the scheme:
• Massages (except where certified as medically necessary).
• Cosmetic treatment unless relating to an accident.
• Treatment other than that done by a registered medical practitioner.
• Injuries as a result of active participation in war, invasion, riots or terrorism.
• Nutritional supplements unless prescribed by a doctor as part of the treatment of a deficiency.
• Maternity cover for dependent children.
• Medical expenses following attempted suicide.
• Self-prescribed drugs.
• Infertility investigations and family planning procedures and expenses.
• Outpatient,dental and optical co-pay of Ksh. 50/= on each visit.
• Cosmetic dental care – cosmetic crowns, caps, bridges, orthodontics & dentures, self- prescribed teeth cleaning and whitening, unless necessitated by accidental injury.
• Replacement and repair of old dentures, bridges and plates unless damage to dentures, bridges and plates becomes necessary as a result of an accident .
• Replacement of spectacle frames within the same year of cover.
• Reimbursement of costs incurred outside the appointed panel of providers unless for emergency cases, accident cases and only cases that have been pre-authorised by Minet.
• Private vaccines and travel vaccines.
• Alcohol related rehabilitation.
• Photo chromatic and/or antiglare lenses are excluded unless they form part the prescription lenses.
• Treatment otherwise covered by NHIF.
Dial *865# from your Safaricom or Airtel mobile phone number.
Key in your TSC and National ID Numbers when prompted. The details will be verified against our database.
If successful, you will be prompted to enter your name (surname and other name), role and gender.
*Once done, you will receive a message confirming your successful registration onto the scheme and a prompt to register dependants.
Dial *865# from your Safaricom or Airtel mobile phone number
Select the dependant you wish to register i.e spouse or child
Enter Relation, full names, Disability status, Date of birth, ID number if you are over 18 years.
After successful registration the member will recieve a link to complete the registration process: https://collaborationkenya.minet.com/TSC
If not successful, kindly contact us on our call centre hotline number 1528 for further assistance.
Procedure for access to medical cover under the scheme
Members of the Teachers’ Medical Scheme can access any of the service providers on our panel countrywide. This list is accessible via USSD code *340# or Minet/TSC Website.
Present yourself at the service provider on our active panel.
Identify yourself or your dependant with the TSC number
The service provider will generate an SMS that contains a One-Time-Pin (OTP), sent to the principal member’s registered mobile number.
You will present this OTP to the service provider representative to register the fingerprints.
You will be requested to place a finger on the biometric device and the impressions will be saved against your membership record.
On successful registration the member or dependant can access medical services.
NB: Children under 5 years of age will be registered under either the parent or an appointed guardian.
These are primary care facilities that members can access directly without the need of a referral letter.
These are facilities that offer medical services for cases that require specialised treatment. A Referral letter from a direct facility is required to access medical services in these facilities.
Scheme member education is a continuous process to sensitise members on the operation of the medical scheme.