The government has threatened to arrest a section of Kenyans over a series of fraud schemes targeting the Social Health Authority (SHA) Fund.
Health Cabinet Secretary Aden Duale raised alarm over a trend of scams perpetrated by various stakeholders, including hospitals, health workers and in some bizarre cases, patients.
"We have noted with great concern a growing trend of fraudulent activities being perpetrated by some healthcare facilities, healthcare workers, and even patients against the Social Health Authority (SHA) Fund. These actions are illegal, unethical, and a direct betrayal of the trust placed in our health system," Duale said in a statement.
Among the schemes the CS flagged was the deliberate misinterpretation of medical claims. In this case, some facilities convert outpatient visits into inpatient claims to inflate reimbursements.
In his warning, Duale said medical facilities found engaging in such activities would not only be shut down but would face prosecution as well.
Another worrying trend the government has been made aware of is the unnecessary hospital admissions where facilities coerce health workers to admit patients without any medical justification to increase claim values. The CS noted that in such scams, individual medical practitioners and facility owners would be held accountable if caught.
The ministry also flagged some patients who, despite initially lamenting about some of SHA's inefficiencies, have now joined the trend of fraudulent activities in the cover. In some cases, patients reportedly share their access codes with hospitals to facilitate the submission of fraudulent documents for services that were not actually rendered.
Such acts, according to Duale, amounted to criminal fraud and can warrant an arrest and legal consequences.
Further, the government also flagged cases of doctors sharing pre-authorisation codes inappropriately to enable fraudulent billing, which is a blatant violation of professional conduct.
Some facilities have also been accused of double billing by unscrupulous health facilities, who charge them using the SHA fund while also demanding cash for the same services. The government deems this illegal, with patients who have experienced such incidents encouraged to report directly to the SHA Call Centre by dialling 147.
But perhaps the most outrageous fraud scheme flagged by the government was the reports of ghost patients. According to Duale, some facilities end up filing claims for nonexistent individuals. Some hospitals also exceed their bed capacity in a bid to collect higher payouts.
This is the latest crackdown by the government on fraud surrounding SHA, amid an intense effort to clean up the scheme's image.
Just recently, on April 14, the Health Cabinet Secretary announced a crackdown on unqualified health practitioners and those using fraudulent means to receive funds from the national insurance scheme, as well as facilities operating unlawfully in the country.
