The government has intensified crackdown on fraud in the health sector, warning that facilities, doctors and patients found culpable will face prosecution.
In a press briefing on Monday, Health Cabinet Secretary Aden Duale revealed that fraudulent claims worth Ksh10.6 billion had been rejected under the Social Health Insurance Fund (SHIF), while another Ksh5.1 billion in claims is under reevaluation for possible fraud.
The CS refuted claims of payments to ghost hospitals saying the government will not relent in protecting public resources meant for universal healthcare.
“Our commitment to an uncompromising stance against fraud is a foundational pillar of the Taifa Care program. Every shilling contributed to the Social Health Insurance Fund must go towards legitimate, life-saving healthcare,” Duale stated.
Since the rollout of Taifa Care on October 1, 2024, Duale noted that health facilities have submitted claims totaling Ksh91.7 billion. Out of this, Ksh60.7 billion has been paid, while Ksh6.4 billion has been approved and is awaiting disbursement.
Claims worth Ksh3 billion are undergoing reevaluation due to missing documents, Ksh2.1 billion are under surveillance, and Ksh7.6 billion for August remain under review.
The CS stressed that fraudulent providers will not only be struck off but also compelled to refund the money and face criminal prosecution.
He urged Kenyans to report suspected fraud through SHA’s toll-free line, 147.
“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,” he stated.
Alarming fraud schemes uncovered
According to Duale, investigations have uncovered alarming schemes, including upcoding of procedures, falsification of records, converting outpatient visits into inpatient admissions, and phantom billing for non-existent patients.
Among those implicated are Nabuala Hospital in Bungoma, which allegedly filed multiple Caesarean section claims for the same patient within days, and Jambo Jipya Hospital in Mtwapa, accused of billing for surgeries where patients had normal deliveries.
The CS disclosed that several facilities in Mandera colluded to submit 312 fraudulent claims for patients who were allegedly admitted on the same dates across multiple facilities simultaneously.
Other cases include falsified documentation at Kotiende Medical Centre in Homa Bay, suspicious inpatient admissions at Vebeneza Medical Centre in Nairobi, and exaggerated admissions at New Manyalo Nursing Home in Wajir.
He added that the ministry’s intensified enforcement has led to the closure of 728 non-compliant facilities, the downgrading of 301 more, and the suspension of 40 hospitals last month through a Gazette Notice with investigations now targeting 45 additional facilities flagged for fraudulent activities.
On the NHIF legacy debt, Duale said the government will settle all verified claims of up to Ksh10 million as directed by President William Ruto, while larger claims will undergo rigorous verification before payment.
