Hospitals Face Delays as SHA Blocks Ksh 3 Billion Claims

Hospitals and clinics seeking payments from the Social Health Authority (SHA) are facing delays after the agency put on hold claims valued at more than Ksh 3 billion.

The authority says many of the submissions did not meet documentation requirements, forcing a freeze until providers furnish extra paperwork.

“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 issued on Monday, September 15, 2025, read.

According to SHA, no claim is complete without three essential documents: a claim form, an itemised invoice, and a discharge or case summary.

In several cases, facilities failed to provide further paperwork demanded by the review teams, making it impossible to finalise payments.

To close the gap, the authority is rolling out a “Missing Documents Resubmission Module” beginning September 16. Once a claim is flagged, providers will have 14 days to upload the missing documents.

The deadline for the current flagged claims is September 30, after which they will be rejected. To prevent tampering, the system will not allow deletion or replacement of earlier uploads.

Patients will also be alerted each time a claim is resubmitted. SHA Chief Executive Officer Mercy Mwangangi has urged facilities to comply without delay.

The stricter approach comes as the government intensifies its war on health sector fraud. Earlier this month, Health Cabinet Secretary Aden Duale suspended 85 facilities after an audit unearthed shocking malpractice.

Investigators found falsified medical reports, billing for patients who never existed, and inflation of simple procedures into expensive ones. Duale confirmed that evidence from the audit had already been handed over to the Directorate of Criminal Investigations.

Concerns are also growing over the incomplete transfer of financial data from the defunct National Hospital Insurance Fund to the SHA.

In March 2025, SHA released Ksh 11.4 billion to hospitals, only for scrutiny to reveal that small private facilities had pocketed unusually large sums.

Civil society groups and doctors raised questions, pointing out that some of the hospitals either did not exist or grossly exaggerated their claims.

Health CS Duale later revealed that investigators uncovered duplicate claims, false records, ghost patients, and even cases where funds were sent to a hospital that turned out to be a patch of bushland.

The clean-up continued on August 7, 2025, when a Kenya Gazette notice listed 40 hospitals and 12 medics suspended from the scheme after another forensic audit.

SHA has denied some reports, including one that Nyandiwa Hospital received Ksh20 million, but public anger has not eased.

Oversight agencies have also criticised the authority’s systems. The Auditor General flagged irregularities in the tendering process for SHA’s digital platform, while civil society groups argue the lapses resemble the NHIF scandal. A court ruling in May 2025 confirmed that NHIF had, for years, lost money through ghost patients and exaggerated claims.