Hospitals, medical professionals face suspensions as corruption investigations intensify within the State Health Authority
The Kenyan Ministry of Health has suspended 40 health facilities, eight doctors, and four clinicians from accessing services under the Social Health Authority (SHA) following a digital audit and forensic review of suspicious claims lodged over the past two months.
The audit, which was conducted to ensure transparency and accountability in the healthcare system, uncovered four main ways in which hospitals were defrauding SHA: upcoding, falsifying medical records, converting outpatients into inpatients, and exaggerating simple outpatient visits into extended hospital stays.
One of the most prevalent fraudulent practices, known as upcoding, involves claiming payment for more expensive procedures than those actually performed. For instance, a hospital billed Sh201,600 for a Transurethral Resection of Bladder Tumor, a procedure worth Sh201,600, but had actually performed a cheaper prostatectomy worth Sh89,600.
Another practice is falsification of records and altered patient information, where false medical records or claims for patients admitted to other hospitals at the same time are submitted. Some facilities have been found to convert outpatient visits to inpatient care, inflating claims to receive higher payments, a practice notable in Nairobi and Homa Bay counties.
Multiple billing and ghost patients, a form of collusion between facilities, was also discovered, with specific cases in Mandera involving coordinated fraudulent claims among facilities.
In response to these findings, the Ministry has revoked the access of the implicated healthcare professionals to SHA and Digital Health Authority platforms and notified the Kenya Medical Practitioners and Dentists Council (KMPDC) and the Clinical Officers Council (COC) for immediate disciplinary action.
The Ministry is also implementing biometric verification at lower-level facilities to curb abuse and has warned that those who made money under the defunct National Health Insurance Fund (NHIF) should find another business, as fraudulent activities will not be tolerated in the SHA era.
Patients are advised to be vigilant and not share their SHA one-time passwords (OTPs) or identification details with anyone, as some level 2 and 3 facilities have been using them to process fake claims. If a patient's OTP is used to defraud the SHA, they will also be held liable.
The Ministry commends whistleblowers who have exposed cases of patients being billed twice and facilities charging both SHA and out-of-pocket payments from patients. Kenyans are urged to report suspected fraudulent activities directly to SHA via hotline 147.
The suspended hospitals will only be reinstated after meeting corrective measures ordered by regulators such as the KMPDC. The Directorate of Criminal Investigations will also receive the full list of implicated facilities and professionals for possible prosecution.
Primary healthcare services, including outpatient consultations, medication, and laboratory tests at public, private, and faith-based facilities are fully covered by the government through the Primary Healthcare Fund, which has a budget of Sh13 billion this year.
This crackdown follows President William Ruto's recent warning that fraudulent activities seen under the defunct NHIF will not be tolerated in the SHA era. The Ministry's crackdown on fraudulent activities will continue, backed by SHA's real-time digital monitoring system.
[1] Ministry of Health Press Release, [link to press release] [2] The Star, "Ministry of Health Suspends 40 Health Facilities Over Fraudulent Claims," [link to article] [3] The Nation, "40 Hospitals Suspended Over Fraudulent Claims," [link to article] [4] Capital FM, "Ministry of Health Suspends 40 Health Facilities Over Fraudulent Claims," [link to article] [5] Daily Nation, "Ministry of Health Suspends 40 Health Facilities Over Fraudulent Claims," [link to article]
- The Ministry of Health's ongoing crackdown on fraudulent activities in the healthcare system, sparked by President William Ruto's recent warnings, has resulted in the suspension of 40 health facilities, eight doctors, and four clinicians.
- In an effort to ensure transparency and accountability, the ministry conducted digital audits and forensic reviews, uncovering several ways in which hospitals were defrauding the Social Health Authority (SHA).
- Among these fraudulent practices discovered was upcoding, where hospitals billed for more expensive procedures than those actually performed, such as billing Sh201,600 for a Transurethral Resection of Bladder Tumor when a cheaper prostatectomy was performed.
- The suspension of these facilities, medical professionals, and the implementation of biometric verification at lower-level facilities are steps towards curbing abuse and improving the integrity of the SHA, with the goal of enhancing health and wellness for all Kenyans.
