The Social Health Authority (SHA) has put on hold claims worth more than Ksh3 billion after identifying gaps in supporting documents. The flagged claims were detected during a routine review of submissions from hospitals and clinics, as stated by the authority in a notice on Monday, September 15, 2025.

“As part of the routine claims adjudication exercise, SHA has flagged over 3 billion worth of claims that require more documentation to assist the review teams to adjudicate the claim,” the notice read.

According to SHA, every claim must include three mandatory documents: a duly filled claim form, an itemised invoice, and a discharge or case summary. However, some facilities have failed to provide extra paperwork requested by review teams. Without this, SHA cannot finalise payments.

To address the issue, SHA has enabled a “Missing Documents Resubmission Module” on its system starting September 16, 2025. Healthcare providers will now have 14 days to submit the required documents. The timer begins once a claim is flagged, and once the window closes on September 30, the claims will be rejected.

The authority has also introduced measures to safeguard integrity. Providers cannot delete or replace previously uploaded files, ensuring all submissions remain visible in their original form. Patients will also receive notifications when a claim is resubmitted. SHA Chief Executive Officer Mercy Mwangangi urged providers to act quickly.

Tightening oversight on fraud

The enforcement comes against a backdrop of increased scrutiny in the health sector. Earlier this month, Health Cabinet Secretary Aden Duale suspended 85 facilities after a forensic audit revealed fraudulent activities. Investigations found altered medical reports, billing for ghost patients, and inflating simple procedures into costlier ones. Duale confirmed that evidence from the audit had been submitted to the Directorate of Criminal Investigations (DCI).

The crackdown is part of a wider effort to clean up the sector, which has faced decades of corruption scandals. SHA recently reported blocking more than Ksh10 billion in fraudulent claims since the rollout of TaifaCare. Hundreds of non-compliant facilities have also been shut down.

While the measures aim to protect public funds, concerns remain about the impact on genuine providers, especially small facilities serving rural areas. Some health workers argue that the system itself is weak and creates loopholes exploited by fraudsters.

For now, facilities with pending claims must focus on compliance. SHA has confirmed that county surveillance teams will begin visiting hospitals from September 16 to monitor adherence. Facilities that fail to cooperate or meet the requirements risk being locked out of future reimbursements.