Duale defends SHA’s rejection of Sh10.8bn in claims citing fraud » Capital News
NAIROBI, Kenya, Aug 25 – Health Cabinet Secretary Aden Duale has defended the rejection of Sh10.6 billion woth of medical claims by the Social Health Authority (SHA) citing fraud.
Duale said SHA flagged the affected facilities for non-compliance as the government intensifies its crackdown on healthcare fraud.
Speaking at Afya House on Monday, Duale said an additional Sh3 billion in claims is under re-evaluation because of missing documents, while Sh2.1 billion remains under surveillance pending further investigation.
“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,” Duale said, defending the ministry against allegations of fraudulent payments to hospitals.
The CS defended SHA’s claims review process as “rigorous and necessary”.
He Section 35(2) of the Social Health Insurance Act, 2023, manadates the Authority to validate medical claims and conduct quality assurance surveillance.
According to Duale, health facilities have so far submitted claims totaling Sh82.7 billion.
Out of the sum, SHA has paid Sh53 billion and approved claims worth Sh6.4 billion pending disbursement.
These payments, he said, cover a portion of July that SHA will settle in the next cycle.
Fraud detection
Duale explained that SHA’s digital claims system, rolled out in October 2024 under the TaifaCare program, detects fraud at every stage of processing.
The system has flagged irregularities including upcoding, falsification of medical records, phantom billing, and illegal conversion of outpatient visits into inpatient claims.
As a result, 728 non-compliant health facilities have been shut down, with another 301 downgraded.
Additionally, forty facilities were suspended earlier this month, and forty-five more are set to be degazetted following forensic audits.
Some of the fraudulent practices exposed include hospitals billing multiple caesarean sections for the same patient, admitting non-existent patients across several facilities simultaneously, and inflating routine outpatient visits into expensive inpatient claims.
Impending prosecution
Duale stressed that fraudulent providers will face prosecution and permanent removal from the SHA system.
“To all healthcare providers: consider this a final warning,” Duale cautioned.
“We are watching. Any facility, doctor, or patient found to [be] involved in fraudulent activities will [be] held liable and face the full force of the law.”
He urged members of the public to report suspicious activity through SHA’s toll-free line 147, adding that the ministry has already begun recovering wrongfully paid funds in collaboration with law enforcement agencies.
On the NHIF legacy debt, the CS said the government will honor all verified claims of up to Sh10 million through a supplementary budget, while larger claims will undergo fresh audits before payment.
Reaffirming the ministry’s stance, Duale said the crackdown on healthcare fraud is “a necessity, not an option,” pointing out that fraudulent claims account for up to 30 percent of insurance payouts in Kenya.
“Our strategy is to build a robust, corruption-proof system,” he concluded.