The Ministry of Health has uncovered a troubling pattern of fraud among healthcare facilities participating in the Social Health Insurance (SHA) program.
In a statement on Monday, August 25, Health Cabinet Secretary Aden Duale said audits revealed that some hospitals and clinics have been inflating bills, falsifying records, and submitting claims for services that were never provided.
According to the CS, investigators found that certain facilities were engaging in upcoding, billing patients for more expensive procedures than those actually performed. Other institutions were involved in falsifying records, altering or creating medical documents in direct violation of the Social Health Insurance Act and its regulations.
The audits also uncovered cases where outpatient visits were illegally converted into inpatient admissions, allowing facilities to claim higher reimbursements. There were even instances of phantom billing, where facilities submitted charges for patients who did not exist.
Duale provided specific examples of the fraud uncovered in the Social Health Insurance (SHA) program. Nabuala Hospital in Bungoma submitted multiple Caesarean section claims for the same patient within a short period, alongside unsupported maternity claims. Kotiende Medical Centre in Homa Bay fabricated clinical documents, with one individual signing off for both day and night shifts over consecutive days.
In Nairobi, Vebeneza Medical Centre reportedly converted outpatient visits into inpatient claims and repeatedly admitted its own employees under suspicious circumstances. Other facilities, including Jambo Jipya Hospital in Mtwapa and New Manyalo Nursing Home in Wajir, submitted fraudulent claims for normal deliveries and exceeded bed capacity by admitting patients already registered elsewhere.
In Mandera, a network of facilities allegedly colluded to submit over 300 claims for patients supposedly admitted on the same dates across multiple locations.
“This is just a brief overview. We will make a detailed report public to ensure full transparency. To all healthcare providers: consider this a final warning. 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.
“We’ve already initiated the process to recover paid monies and will involve law enforcement to prosecute perpetrators,” the CS said.
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