NAIROBI, Kenya, Sep 1 – The Ministry of Health has formally handed over 1,188 case files and supporting evidence to the Directorate of Criminal Investigations (DCI) for further investigation and prosecution of widespread fraud within the Social Health Authority (SHA) that has undermined patient care and depleted public resources.
This follows an intensive forensic review and a comprehensive digital audit that led to the closure of 1,300 health facilities implicated in fraudulent or non-compliant practices.
Offenses uncovered include upcoding, falsification of records, conversion of outpatient services into inpatient claims, and phantom billing.
“The rigorous forensic audits and the digital system have uncovered deeply troubling patterns of fraud that directly harm the public, hence deplete the management’s resources for the care of our patients,” Health Cabinet Secretary said.
“These fraudulent practices include, among others, number one, the upcoding, where billing for more expensive procedures is being claimed than what was actually performed by health care providers,” he stated.
Out of the total files submitted, 190 came from the SHA itself.
These cover 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).
The regulator separately submitted 998 files involving facilities that were either unregistered, unlicensed, or operating far below the required medical standards.
The revelations come amidst mounting scrutiny on SHA.
The authority unveiled in 2024 to replace the defunct National Health Insurance Fund (NHIF) has been rocked by scandals, with more than Sh10.6 billion in fraudulent claims flagged and hundreds of non-compliant facilities shut down since the rollout.
Investigations have led to the suspension of more than 40 health facilities and the closure of at least 31 hospitals accused of billing irregularities, including ghost patients and duplicate claims.
