The Social Health Authority (SHA) has recovered at least Sh300 million from fraudulent claims, with more cases still under investigation by the Directorate of Criminal Investigations (DCI), the authority has said.
SHA Chief Executive Officer (CEO) Dr Mercy Mwangangi said the authority was pursuing suspected fraud through several channels, including internal investigations, administrative action, the DCI, the Office of the Director of Public Prosecutions (ODPP) and the courts.
“We have been able to recover close to Sh300 million to date, and we are still recovering more,” said Dr Mwangangi.
Speaking to the media, the CEO said some providers had admitted to fraudulent claims and voluntarily refunded the money, while other cases were yet to be determined.
Currently, about 15 cases are before the courts, undergoing judicial process, whereas others are being handled by the DCI and ODPP.
The authority is also investigating cases internally, with some expected to be handed over to DCI and ODPP for more investigations and action.
“Cases under DCI are still ongoing, not yet determined, whereas those in court are undergoing judicial process,” added Mwangangi.
Mwangangi’s revelations on fraud come as SHA grapples with a large claims backlog with questions arising over its sustainability.
SHA is currently holding about Sh29 billion in cumulated claims submitted by healthcare providers.
Of the claims submitted, about Sh17 billion have been rejected or returned to providers for correction, according to SHA.
The authority said returned claims are not necessarily lost claims.
Additionally, the claims could be inflated which a provider is granted at least 14 days to rework on them before having them approved for payment.
A number of the claims she said are return claims, where a provider has sent to us, and for some reason, there's a deterministic component in them.
Mwangangi maintained that all claims are digital, and hospitals need to go through change management to understand digital operations more.
However, the CEO said SHA was working towards ensuring all the claims are settled within 90 days.
“We have a 90-day ageing contract,” she said, noting that the authority has resources to settle outstanding claims.
The claims and fraud challenges come as SHA seeks to expand its contribution base, particularly among workers in the informal sector
Data shows 32.2 million Kenyans are registered with SHA, numbers that include principal members and their dependants.
Of the numbers, 10 million are dependants.
About 3.5 million of the registered members are individuals in the formal sector who contribute their premiums through deductions processed by the Kenya Revenue Authority (KRA).
Individuals from the informal sector contributing their premiums are 1.2 million.
“It is about 5 million remitting their premiums; if not able to contribute, then there is a sponsorship program that takes care of indigents and vulnerable groups,” said the SHA boss.
Foreigners and refugees are also being onboarded to SHA.
To be onboarded, foreigners are required to present an alien card, whereas refugees should have a card used for registration; without it, SHA warned they will not be registered.
She insisted that the SHIF fund is contributory, and that people benefiting from the fund are those who register, and paid for, that fund.
According to Mwangangi, SHIF, from formal contributor fetch Sh80 billion a month, while informal-sector collections fluctuate between Sh500 million and Sh700 million.
“SHIF is contributory. The people benefiting from the fund are those who register and pay into the fund,” added Mwangangi.
Additionally, Mwangangi said SHA is also looking at new ways of enrolling informal-sector workers and encouraging regular premium payments, including the use of agents
The authority also said all Level Two facilities across the country should provide free maternal services following a policy change intended to improve access.
During the media briefing, Health Cabinet Secretary Aden Duale directed all hospitals at Level 2, 3 and some 4 to offer free services to patients.
The hospitals, he maintained, are paid an allocation from the Primary Healthcare Fund (PHC), from the exchequer.
“It is criminal to charge Kenyans for primary healthcare services. There is a facility improvement fund, with money being paid to the hospitals. These hospitals are receiving between Sh2 million and Sh5 million, money that was never provided under NHIF,” said Duale.
The National Treasury allocated Sh27 billion for PHC, of which, Sh23 billion has been paid to providers for PHC services.
Additionally, since SHA’s interception, SHIF contributions have fetched Sh151 billion, with SH134.7 billion paid for claims.
Meanwhile, the authority is reviewing its benefits package, with changes expected to trigger fresh debate among healthcare providers.
The review will consider the cost and coverage of procedures, including surgery, dental and optical services, as well as requests for hearing aids and other specialised care.
Some surgical tariffs could be reduced when the review is completed, a move that Dr Mwangangi warned could attract resistance from surgeons and other industry players.
She said the benefit package would continue to expand as more resources become available.
For now, basic dental procedures such as tooth extractions are covered under primary healthcare, while more complex procedures remain outside the package.
On maternal healthcare, SHA said mothers can access delivery services at dispensaries and health centres without paying out of pocket.
Teenagers are also able to access SHA services through issuance of a temporary ID, and when they turn above 18 years, they onboard into the system.
“IDs are necessary. ID is needed for identification,” said the SHA CEO.
Also present was CoG Ceo Mary Mwiti, who said the reforms at the health sector have improved services across all 47 counties.
“These reforms advance an agenda that is citizen-centered,” she said.
On strike, she said services are ongoing in most counties, apart from a few, an issue being addressed by CoG and all stakeholders.
