Duale says Ksh.5.1B in SHA claims under probe amid fraud crackdown

Health Cabinet Secretary Aden Duale on Monday said claims worth Ksh.5.1 billion submitted to the Social Health Authority (SHA) are under re-evaluation and surveillance as the government cracks down on fraudulent billing by health facilities.

In a statement, Duale said that since the rollout of TaifaCare last October, SHA had received claims totalling Ksh.91.7 billion from hospitals under the Primary Health Care (PHC) and Social Health Insurance Fund (SHIF) schemes.

Of these, Ksh.60.7 billion has been paid out, with Ksh.6.4 billion already approved and awaiting disbursement.

But Duale said not all claims were legitimate: “Claims worth Ksh.3 billion are being re-evaluated due to missing documents, while an additional Ksh.2.1 billion is under surveillance for further investigation,” he said.

The ministry has also rejected Ksh.10.6 billion in claims, citing fraudulent practices such as upcoding, falsification of medical records, conversion of outpatient cases into inpatient admissions, and phantom billing for non-existent patients.

Duale highlighted recent audits that uncovered malpractice, including cases at Nabuala Hospital in Bungoma, which reportedly submitted falsified maternity claims such as multiple caesarean sections on the same patient within days.

Another facility, Kotiende Medical Centre in Homa Bay, is also accused of producing fabricated clinical records signed by a single individual for both day and night shifts over consecutive days.

“These actions contravene Section 48(5) of the Social Health Insurance Act, 2023, which prescribes penalties for providers who knowingly alter or falsify information to defraud the Authority,” Duale said.

In total, the minister said, SHA data indicates that Ksh.9 billion in PHC claims have been submitted, of which Ksh.7.7 billion has been paid.

Similarly, Ksh.82.7 billion in SHIF claims were submitted, with Ksh.53 billion already disbursed. Some Ksh.7.6 billion in claims for August is, meanwhile, currently under review.