“Every Shilling Accounted For,” Mwangangi says as SHA Blocks Ksh 10.6B Fake Claims

The Social Health Authority (SHA) has restated its pledge to uphold transparency and accountability in handling health claims, even as questions arise over alleged fund disbursement irregularities.

Speaking on Thursday, SHA Chief Executive Officer Mercy Mwangangi assured Kenyans that the Authority accounts for every shilling it manages, relying on a strict claims review system created under the Social Health Insurance Act, 2023.

She revealed that since the fund began operating, health facilities have submitted claims amounting to Ksh 82.7 billion under the Social Health Insurance Fund (SHIF).

Out of this, SHA has already paid Ksh 53 billion in verified claims and cleared Ksh 6.4 billion for settlement in the upcoming cycle. Dr. Mwangangi stressed that only claims meeting all the set standards receive approval.

“Approval means that all mandatory documents were attached, the claim passed verification checks, the treatment and billing were consistent with the case summary, and the claim fully met SHA’s requirements. Such claims are cleared for settlement,” she explained.

Dr. Mwangangi confirmed that SHA has already rejected claims worth Ksh 10.6 billion after uncovering fraudulent activity or non-compliance.

“This action is taken under the authority of Section 48(5) of the Social Health Insurance Act, 2023, which outlines penalties for providers who knowingly or fraudulently alter information to defraud the Authority. The most common reasons for rejection include upcoding of services, mismatches between services claimed and those offered, phantom billing, unwarranted treatment, or the use of non-standard claim forms,” she stated.

She added that the Authority has flagged Ksh 3 billion in claims for re-evaluation due to missing documents, directed Ksh 2.1 billion to further surveillance and on-site verification, and is currently reviewing another Ksh 7.6 billion submitted in August.

According to Dr. Mwangangi, SHA orders re-evaluation when key supporting documents such as birth notifications, theatre notes, lab results, or imaging reports nare missing. She noted that facilities with such claims will have fourteen days to resubmit the required paperwork.

On Primary Health Care (PHC) claims, she revealed that health facilities have submitted Ksh 9 billion. Out of this, SHA has already settled Ksh 7.7 billion, with the remainder scheduled for payment in the next cycle.

To further support providers, Dr. Mwangangi announced that SHA will host virtual Provider Clinics. These sessions will walk providers through the claims process, covering approvals, rejections, and surveillance referrals. She explained that the initiative is designed to strengthen compliance, improve documentation, and ensure the timely settlement of valid claims.

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