Up to 40 health facilities in Kenya have been temporary barred from billing the Social Health Authority (SHA) for fraudulent activities including upcoding, falsifying records, fake inpatient billing, multiple billing, and for filing ghost patients.

This action comes  just a few days after Health Cabinet Secretary Aden Duale said he will be cracking the whip on corrupt practices in the sector.

The Ministry of Health has suspended 40 health facilities nationwide after a forensic audit by the Social Health Authority (SHA) uncovered fraudulent claims, including upcoding, falsified records, fake inpatient billing, multiple billing, and ghost patients

Also affected in the drastic move by the ministry will be 12 health professionals who have been caught engaging in fraudulent activities involving SHA.

“They [40 health facilities] have engaged in corruption and theft of public resources. The suspension is effective immediately,” Duale stated during a media briefing on Friday.

In a gazette notice issued by SHA Chief Executive Officer, Dr. Mercy Mwangangi hours after, the authority said the suspended facilities will be denied access to any benefits from SHA throughout the investigation period.

Surcharge clinics

“We will be surcharging them to recover any money already paid to them on the basis of these fraudulent claims,” Dr. Mwangangi noted.

According to CS Duale some health facilities, particularly in Nairobi and Homa Bay, were fraudulently converting outpatient cases into inpatient ones. 

He explained that some hospitals submitted claims for more expensive procedures than those performed.

“For example, a facility in Nairobi lodged a claim for a more expensive procedure which was worth KES201,600 after having only performed a process worth KES89,600, in essence claiming more than KES112,000 from what was correctly due,” said Duale.

CS Duale also flagged cases of hospital billing for patients already admitted in other facilities.

Among the affected facilities are several in Homa Bay County, including Rachuonyo County Hospital, Kotiende Medical Centre, Nyatoto Health Centre, Queen Rivers Medical Centre, Archprime Medical Clinic Oyugis, and Torics Nursing Home. 

In Nairobi, the suspended are Salama Yard Medical Centre, Vebeneza Medical Centre-Tassia, ABM Specialized Hospital, Imara Healthcare Centre, Dolma Medical Center, Lengo Medical, St. Johns Hospital Ltd, Edris Premier Hospital Limited, Bristol Park Hospital Fedha, and Selacare Health Services. 

Other centres are spread across Busia, Bungoma, Kakamega, Kajiado, Kilifi, Kirinyaga, Mandera and Vihiga counties.

At the same time the Ministry of Health has suspended user rights of eight doctors and four clinicians over their alleged plan to defraud SHA.

Forensic audit

Duale said their suspension followed a forensic audit and digital investigation which revealed fraudulent activity linked to health facilities in multiple counties.

"These are eight doctors associated with the facilities in Nairobi, Bungoma and Kilifi counties, and four clinicians associated with the facilities in Nairobi, and Homa Bay counties," the CS explained. 

In response to the findings, the ministry has moved to restrict the affected medical personnel from accessing public health systems.

"SHA has immediately withdrawn the user rights for these doctors and clinical officers from all the authority and the digital health platforms. We have also informed the regulator, Kenya Medical Practitioners and Dentists Council and Clinical Officers Council of Kenya to implement the decision that we have made today" he added.

According to Duale, the implicated health professionals are connected to some of the 40 facilities that have also been suspended for allegedly defrauding SHA.

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