How SHA blocked Sh10.6bn in fake medical claims

By Newsflash Reporter

The Social Health Authority (SHA) has shielded taxpayers from losing Sh10.6 billion by rejecting fraudulent medical insurance claims, the Ministry of Health has announced.

The rejected claims involved inflated billing for procedures, forged records for non-existent patients, and the manipulation of outpatient cases into inpatient admissions.

Health Cabinet Secretary Aden Duale, speaking in Nairobi on Monday, August 25. confirmed that the ongoing crackdown on health insurance fraud has led to the closure of 728 rogue facilities and the downgrading of 301 others, with 45 more hospitals set to be deregistered.

“Our robust digital system was designed to plug loopholes that plagued the defunct NHIF,” Mr. Duale said, noting that SHA’s automated claims management platform forms the core of the anti-fraud campaign. He stressed that as the AI module continues learning from data, the system becomes sharper in flagging anomalies.

Rogue hospitals exposed

Mr. Duale revealed how hospitals had devised elaborate schemes to defraud SHA. At Nabuala Hospital in Bungoma, multiple Caesarean section claims were filed for the same patient within days, while in Homa Bay, Kotiende Medical Centre fabricated records with one staffer signing off as both day and night doctor.

Vebeneza Medical Centre in Nairobi was found converting outpatient visits into inpatient admissions, even admitting its own staff. At Mtwapa, Jambo Jipya Hospital billed for a Caesarean section where the mother delivered normally. In Wajir, New Manyalo Nursing Home exaggerated its bed capacity by double-admitting patients also registered elsewhere.

In Mandera, a network of hospitals, including Al-Masry, Rhamu Dimtu, Balanga, Care Connect, Al Shamsi, Merti, Zamzam, and Nibil Nursing Homes, colluded to lodge 312 fraudulent claims for patients allegedly admitted simultaneously across different facilities.

“These cases highlight the depth of dishonesty,” Mr. Duale said. “Any doctor, facility, or patient engaged in fraud will face consequences. We have already begun recovering funds and will prosecute perpetrators.”

Questions over Sh104.8bn IT project

Despite defending the system, Mr. Duale faced questions surrounding the Sh104.8 billion Healthcare Information Technology Digitisation Project that supports SHA’s operations. A 2023/24 Auditor-General report flagged procurement flaws, noting the contract failed to state how many facilities the system would cover. It also allocated Sh7 billion for training without specifying the number of health workers involved.

The Auditor-General warned that the contract locks Kenya into a restrictive arrangement since intellectual property rights remain with the contractor consortium. Value for money, the report stated, could not be confirmed.

Mr. Duale, however, insisted that every pending claim from the defunct NHIF will undergo thorough verification in line with the Constitution and the Social Health Insurance Act, 2023. To tighten oversight, he has partnered with top insurers—Jubilee Health, AAR, and Old Mutual—under a Joint Anti-Fraud Action Group.

He dismissed criticism from the Rural Private Hospitals Association (Rupha), clarifying that SHA deals with individual facilities and not associations. “We will protect public funds and only pay genuine claims,” he affirmed, stressing that the government remains committed to building a transparent, corruption-free health financing system.