NAIROBI, Kenya, Jan 28 – Kenya lost Sh11 billion through fraudulent claims submitted to the Social Health Authority (SHA), an audit by the Ministry of Health has revealed.
The audit, conducted between October 2024 and April 2025, found that most of the fake claims originated from private hospitals operating under the Universal Health Coverage (UHC) scheme.
Speaking to the Daily Nation, Health Cabinet Secretary Aden Duale said the government is seeking to recover the lost funds through the reimbursement system.
The audit revealed that some health facilities falsely converted outpatient services into inpatient admissions to claim higher payouts from the National Health Insurance Fund (NHIF), which SHA replaced in 2024.
Other facilities billed for services that were never rendered, inflated charges for the same procedures, or reported unusually high numbers of caesarean sections, far above World Health Organization (WHO) thresholds.
Currently, SHA informs health facilities of rejected claims and specifies documentation required for successful processing.
In September last year, Duale handed over 1,188 case files to the Directorate of Criminal Investigations (DCI), citing widespread fraud that had undermined patient care and drained public resources.
He said the cases include upcoding—where hospitals billed for more expensive procedures than those performed—falsification of medical records, conversion of outpatient visits into inpatient admissions, and phantom billing involving non-existent patients.
Of the total files submitted, 190 originated from SHA and involved 24 facilities with conclusive evidence of fraud, 61 facilities under active investigation, and 105 facilities already closed by the Kenya Medical Practitioners and Dentists Council (KMPDC).
Separately, the regulator submitted 998 files linked to facilities that were unregistered, unlicensed, or operating below required medical standards.
The revelations come amid heightened scrutiny of SHA, which has been hit by repeated scandals since its launch. More than Sh10.6 billion in fraudulent claims have been flagged, with over 40 facilities suspended and at least 31 hospitals shut down for billing irregularities, including ghost patients and duplicate claims.
