Kenya’s Health Cabinet has revealed that the government lost Sh11bn through fraudulent and irregular medical claims under the new Social Health Authority (SHA) system, blaming health facilities for attempting to carry over corrupt practices from the defunct NHIF (National Health Insurance Fund) scheme.
Cabinet Secretary Aden Duale said an audit conducted after he took over the Ministry in April last year uncovered widespread manipulation of claims submitted between October and April, shortly after the roll-out of SHA, reports allAfrica.
The amount represents rejected claims that failed basic medical and legal verification standards, and had been presented to Parliament’s Health Committee for scrutiny, he added.
One of the red flags was the unusually high number of Caesarean section deliveries reported by some hospitals.
“Only about 10% to 15% of births should be C-sections. But we found facilities reporting 100% of mothers delivering through surgery. One private hospital claimed 500 mothers, all through C-section,” he said.
Falsified documentation was also a major source of rejected claims, particularly in maternity services.
Claim forms must be completed by the patient, the attending health worker, and the hospital administrator to confirm that treatment was actually provided.
“When SHA finds that a claim was filled in by just one person, with the same handwriting, the same pen, but in three names, that is automatic rejection. We will not pay that claim,” he said.
The digital system used by SHA is now flagging suspicious patterns in outpatient services under the free primary healthcare programme, he said, citing one example where one patient was recorded as visiting the same facility up to 10 times a day.
Duale said the Ministry was intensifying audits and working with county governments to clean up the system, warning that facilities engaging in fraud risked deregistration and prosecution.
“We are determined to stop this culture of theft in healthcare. The money is for patients, not for cartels,” he said.
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