SHA has blocked Ksh 10.6 billion in fraudulent claims – CEO Mwangangi

The Social Health Authority (SHA) has reaffirmed its commitment to transparency and accountability in managing health claims, despite concerns regarding alleged irregularities in the disbursement of funds.

In a statement on Thursday, SHA Chief Executive Officer Mercy Mwangangi emphasized that every coin in the Authority’s custody is accounted for and safeguarded through a rigorous claims review process established under the Social Health Insurance Act, 2023.

Since its inception, she confirmed that health facilities have submitted claims totaling Ksh 82.7 billion under the Social Health Insurance Fund (SHIF).

Of this amount, SHA has paid Ksh 53 billion in verified claims and approved Ksh 6.4 billion pending settlement in the next cycle. Dr. Mwangangi explained that approvals are granted only when claims meet all necessary requirements.

“Approval means that all mandatory documents were attached, the claim passed verification checks, the treatment and billing were consistent with the case summary, and the claim fully met SHA’s requirements. Such claims are cleared for settlement,” she stated.

However, she confirmed that claims worth Ksh. 10.6 billion have been rejected due to fraudulent activities or non-compliance.

“This action is taken under the authority of Section 48(5) of the Social Health Insurance Act, 2023, which outlines penalties for providers who knowingly or fraudulently alter information to defraud the Authority. The most common reasons for rejection include upcoding of services, mismatches between services claimed and those offered, phantom billing, unwarranted treatment, or the use of non-standard claim forms,” stated Mwangangi.

She noted that the authority has flagged Ksh 3 billion for re-evaluation due to missing documents, sent KES 2.1 billion for further surveillance and on-site verification, and is currently reviewing Ksh 7.6 billion in claims submitted in August.

According to the CEO, re-evaluation applies when essential supplementary documents such as birth notifications, theatre notes, laboratory results, or imaging reports are absent. Facilities with claims in this category will be given fourteen days to resubmit the missing documents.

For Primary Health Care (PHC) claims, she indicated that facilities have submitted Ksh 9 billion, of which Ksh 7.7 billion has already been paid, with the balance due in the next payment cycle.

To support facilities, Mwangangi announced that SHA will host virtual Provider Clinics, to guide providers through the claims process, from approvals and rejections to surveillance referrals. These sessions aim to strengthen compliance, improve documentation, and ensure the smooth settlement of legitimate claims.