The government has intensified its war against corruption in the healthcare sector, rejecting fraudulent claims worth Ksh10.6 billion under the Social Health Authority (SHA). Health facilities have been put on notice, with officials stressing that the review process is not optional but a necessary safeguard to protect public funds.
An additional Ksh3 billion in claims are undergoing re-evaluation due to missing documentation, while another Ksh2.1 billion remains under surveillance for suspected fraud. The crackdown follows rising public concern over corruption within the newly established health insurer, with authorities clarifying that the measures are designed to create a transparent and corruption-proof system.
The investigation has unearthed a wide range of fraudulent practices, including upcoding (billing for costlier procedures than those actually performed), falsification of medical records, phantom billing for non-existent patients, and the illegal conversion of outpatient visits into high-cost inpatient claims. Forensic audits revealed instances such as falsified maternity claims, fabricated documents signed by the same individual across shifts, and repeated billing of the same patients.
In response, decisive regulatory action has been taken against errant facilities. To date, 728 non-compliant health facilities have been shut down, while another 301 have been downgraded by the Kenya Medical Practitioners and Dentists Council (KMPDC). The SHA has also suspended 40 facilities and is in the process of degazetting an additional 45 flagged for fraudulent activities.
Officials have issued a stern warning to all healthcare providers, stating that any facility, doctor, or patient implicated in fraudulent schemes will face prosecution, deregistration, and permanent exclusion from the SHA system. The government has also embarked on the recovery of wrongfully paid funds, working in close collaboration with law enforcement agencies. Members of the public have been urged to report suspicious activities through the SHA toll-free line 147.
Regarding outstanding claims from the defunct National Hospital Insurance Fund (NHIF), authorities have assured that all verified claims up to Ksh10 million will be settled through a supplementary budget. Larger claims will undergo fresh audits before payment to ensure accountability.
Out of Ksh82.7 billion in total claims submitted under the Social Health Insurance Fund (SHIF), Ksh53 billion has already been disbursed, with an additional Ksh6.4 billion approved and awaiting release. The government maintains that only legitimate claims will be honored, reinforcing its commitment to building a sustainable and fraud-free health insurance system.
