Introduction

The Social Health Authority (SHA) has launched a nationwide training programme aimed at improving compliance among health facilities in Kenya with its medical claims review process. This initiative is expected to streamline claims management and reduce fraudulent practices that have hindered the smooth flow of payments under the Social Health Insurance Fund (SHIF) and Primary Health Care (PHC).

Virtual “Provider Clinics” for Facilities

Beginning Wednesday, August 27, SHA rolled out virtual sessions referred to as “Provider Clinics.” These clinics are designed to walk hospitals and clinics through the claims journey, including submission requirements, review mechanisms, grounds for approval or rejection, and compliance expectations.

The training sessions will run until Monday, September 1, with a phased approach targeting different facility levels. Level Four facilities will undergo training on Thursday, followed by Level Three facilities on Friday, and Level Two facilities on Monday.

Findings from Claims Audit

SHA’s training follows an extensive audit of claims submitted to date. According to Chief Executive Officer Dr. Mercy Mwangangi, health facilities have submitted claims worth KSh 91.7 billion. Of these, KSh 60.7 billion has been successfully paid, and KSh 6.4 billion has been approved but is still pending payment.

However, not all claims met compliance standards. Claims worth KSh 10.6 billion were rejected due to fraudulent practices such as upcoding, phantom billing, and unwarranted treatment. Additionally, KSh 3 billion in claims are under re-evaluation due to missing documents, while KSh 2.1 billion has been flagged for surveillance and on-site verification.

Addressing Fraud and Non-Compliance

The SHA emphasized that fraudulent claims and non-compliance remain major obstacles in ensuring effective health financing. The training programme is therefore positioned as a corrective measure to equip health facilities with the knowledge to submit accurate claims and avoid unnecessary rejections or delays.

Dr. Mwangangi stated that the training would help hospitals and clinics align with SHA’s standards, ensuring transparency and accountability in the claims review process.

Conclusion

SHA’s nationwide training marks a pivotal step in Kenya’s health financing reform. By providing health facilities with practical guidance and compliance tools, the Authority seeks to reduce fraud, speed up payments, and strengthen trust between service providers and the regulator. 

Ultimately, this initiative supports the broader goal of making the Social Health Insurance Fund and Primary Health Care programmes sustainable and effective for all Kenyans.