The government is de-gazetting 45 facilities suspected of fraud and will initiate investigations soon after.

Health Ministry suspended 40 health facilities from SHA two weeks ago after following forensic audits, showed they were involved in fraudulent claims for services they did not provide.th suspension was announced vide a Gazette Notice.

Health Cabinet Secretary Aden Duale in a press briefing said that audits have revealed deeply troubling patterns of fraud that include billing for more expensive procedures than those actually performed and submitting altered or false medical documentation and all this contravenes Section 48(5) of the Social Health Insurance Act, 2023, and Regulation 34(2) (f) of the Social Health Insurance Regulations, 2024.

Others are illegally billing for inpatient admissions for what were simple outpatient visits and also submitting claims for services provided to non-existent patients.

He named Nabuala Hospital in Bungoma; Kotiende Medical Centre in Homa Bay; Vebeneza Medical Centre in Nairobi; Jambo Jipya Hospital in Mtwapa and New Manyalo Nursing Home in Wajir, which were among the few engaged in various malpractices but said that the ministry would make a detailed report public to ensure full transparency.

“Healthcare fraud is a global problem, draining an estimated 3 per cent to 15 per cent of healthcare expenditures annually. In Kenya, the Association of Kenya Insurers (AKI) reports that fraudulent claims account for 30 per cent of all pay-outs. This isn’t just a challenge for us; it’s a systemic menace,” the cabinet secretary said.

The minister noted that rigorous enforcement is therefore necessary, adding that since he took office in April, they have intensified the fight.

On claims for re-evaluation, Duale said there are Ksh3 billion ($23.2 million) worth of claims that were being re-evaluated due to missing documents and claims worth Ksh2.1 billion ($16.22 million) are under surveillance for further investigation.

“This rigorous process is a key part of the authority’s function under Section 35(2) of the Social Health Insurance Act, 2023, which mandates the claims office to review, process and validate medical claims and conduct quality assurance surveillance,” he said.

The CS confirmed that for the month of August alone, claims under review total Ksh7.6 billion ($58 million).

Addressing the NHIF Legacy Debt, the cabinet secretary noted that they respect the recent High Court ruling but this would not absolve their duty to ensure public funds are used prudently.

On Monday last week, the High Court ruled on the Pending Medical Claims Verification Committee established by Duale, terming it to be unconstitutional and quashing it for having no statutory basis.

“As committed by His Excellency the President, the government will pay all verified claims of Ksh0-10 million and these payments will be factored into the supplementary budget in full respect of the Constitution and relevant financial acts,” the minister said.

However, Duale noted that claims above this threshold must still undergo a rigorous verification process and that as a government they have a duty to pay only for services legitimately rendered in full respect of Article 201 of the Constitution on the Principles of Public Finance, as well as the Public Finance Management Act and the Social Health Insurance Act, 2023.

Furthermore, the minister said the role of health care associations, saying that SHA contractual agreements were made directly with individual health care facilities, not with associations.

Section 34 of the Social Health Insurance Act, 2023, specifies that the authority negotiates and enters into contracts with individual healthcare facilities.

According to Duale, while they respect the crucial role played by associations such as

RUPHA, it is important to clarify that the government’s primary obligation is to pay for genuine claims and to protect public money.

“All obligations and accountability vest with the contracted parties, his individual facilities and the Social Health Authority. It is the responsibility of each facility to adhere to its contractual and ethical obligations,” Duale said.

Duale had called for a press conference to provide a comprehensive update on the fight against fraud and also to address recent discussions, including those on social media and from various professional associations on the Taifa Care programme.

• A Tell Media / KNA report / By Wangari Ndirangu