SHA begins nationwide training for health facilities on claims review process

The Social Health Authority (SHA) has begun a nationwide training programme for health facilities to enhance compliance with its ongoing medical claims review process.

Starting Wednesday, August 27, SHA will host virtual “Provider Clinics” to guide hospitals and clinics through the claims journey, review mechanisms, and documentation requirements.

The sessions run until Monday, September 1, and will cover the basis for approvals, rejections, surveillance referrals, and compliance expectations.

SHA has scheduled the training in phases, with all Level Four facilities across all counties will be trained on Thursday, with Level Three facilities slotted for Friday. Level Two facilities will, meanwhile, undergo training sessions on Monday.

The training follows an audit of claims submitted under the Social Health Insurance Fund (SHIF) and Primary Health Care (PHC).

According to SHA Chief Executive Officer Mercy Mwangangi, health facilities have submitted claims worth Ksh.91.7 billion to date. Of these, Ksh.60.7 billion has already been paid, while Ksh.6.4 billion has been approved and awaits payment.

However, claims worth KSh 10.6 billion were rejected due to fraudulent practices or non-compliance, including upcoding of services, phantom billing, and unwarranted treatment.

Meanwhile, a further Ksh.3 billion is under re-evaluation due to missing documents, while Ksh.2.1 billion has been flagged for surveillance and on-site verification.

“Training is a critical step in ensuring facilities understand the requirements for proper claims management and can avoid unnecessary rejections or delays,” Dr Mwangangi said in a Wednesday statement.