As Kenya continues the rollout of the Social Health Authority (SHA) to expand universal health coverage, authorities are grappling with attempted fraud.
The malpractices that have been intercepted include falsification of records and fraudulent claims that threaten the integrity of the system.
Currently, 28.1 million Kenyans are registered under SHA.
Past investigations by the Ministry of Health and SHA digital monitoring systems have uncovered multiple schemes used to siphon public funds including upcoding and inflated billing where facilities claim more expensive procedures than those actually performed.
Some of the hospitals have also been flagged over falsification of patients records to inflate the value of claims, conversion of outpatient services to inpatient, to attract higher reimbursements, and multiple billing for same or non-existent patient or for services not rendered.
WIDESPREAD IRREGULATIES
The widespread irregularities prompted August’ suspension of 40 health facilities countrywide for submitting fraudulent claims to SHA
One of the suspended hospitals in Nairobi allegedly claimed Sh201, 600 for a bladder procedure that should have costed Sh89, 600.
There have also been cases of people impersonating SHA officials and scamming members of the public. In October, four suspects were arrested in Marimanti, Tharaka Nithi after defrauding a man Sh251, 000 and convincing him to hand over his phone to them for “complete” registration.
The incident prompted SHA CEO Mercy Mwangangi to caution Kenyans against paying registration fees and do so at the comfort of their homes using USSD code *147# or visit SHA website.
CASES UNDER INVESTIGATIONS
The Ministry of Health in September this year, following an intensive forensic review and digital audit that led to closure of 1300 health facilities, handed over 1188 case files and supporting evidence to the Directorate of Criminal Investigations (DCI) for further probe and prosecution.
Eight doctors and four clinical officers accused of fraud, in August this year, saw their SHA platform access rights withdrawn by the Ministry and their names forwarded to DCI for prosecution.
Some of the current safeguards being used by authorities to prevent fraud include AI powered fraud detection system that monitors every transaction in real-time, detects suspicious activities and blocks fraudulent claims before disbursement.
The system recently rejected Sh10.6 billion worth of fraudulent claims before payments were made, Health CS Aden Duale revealed.
Tying patient identity and service records to biometrics has helped prevent misuse of one-time passwords and credential sharing.
PRACTICE 360 APP
CS Duale, during yesterday’s launch of Intensive Care Unit, Amenity ward at Chuka Level 5 hospital in Tharaka-Nithi, announced January’s planned rollout of the Practice 360 app to fill loopholes among health workers and facilities.
The app is geo-fenced to health facilities and allows healthcare workers to manage SHA pre-authorization claims directly and will block unauthorized code sharing. It will allow medics view, approve and manage the claims digitally.
“SHA will only reimburse claims authorized by Practice 360 and in facilities where the doctor is employed,” he said.
This as a section of Kenyans continue to express widespread frustration with SHA that has prevailed in the last six months following a shift from the monthly to full-year upfront payments, a requirement that has left many unable to access healthcare despite prior contributions.
It could be the reason why only an estimated 20 percent of the total registered Kenyans are actively contributing to the scheme, as majority as ineligible for SHA full benefits.
The faith-based health facilities have for some time lamented reimbursement rates of as low as 38 percent from SHA.
While the scale of fraud exposed has shaken Kenyans’ confidence in the new health financing system, the government maintains that the safeguards are progressively strengthening SHA resilience.
