The Social Health Authority (SHA) and the Kenya Medical Practitioners and Dentists Council (KMPDC) have submitted 1,188 files and supporting evidence to the Directorate of Criminal Investigations (DCI) in a major crackdown on healthcare fraud.
Health Cabinet Secretary Aden Duale, in a statement on Monday, said the action targets fraudulent and non-compliant healthcare facilities and individuals.
SHA has already suspended 85 health facilities to pave way for investigations.
“The rigorous forensic audits and digital systems have uncovered deeply troubling patterns of fraud that directly harm the public and deplete the monies meant for patients,” Duale said.
The fraudulent practices identified include upcoding, falsification of records, conversion of outpatient to inpatient cases, and phantom billings.
Last week, KMPDC closed 544 health facilities and canceled 454 licences.
Of the 1,188 files submitted to the DCI, SHA provided 190 while KMPDC contributed 998. Among SHA’s files, 24 contain already concluded evidence of fraud, 61 relate to ongoing investigations, and 105 are for facilities closed by KMPDC but which had contracts with SHA.
KMPDC’s files cover 998 facilities said to be operating in violation of the law.
“These submissions are a critical step in a multi-agency collaboration that will see the DCI investigate and prosecute those responsible,” Duale said.
Duale reminded healthcare providers that the law prescribes heavy penalties for fraud.
Under Section 48(5) of the Social Health Insurance Act, 2023, facilities that knowingly alter information to defraud the Authority risk fines of up to Sh2 million, suspension, or removal from the register of empanelled providers. SHA has already withdrawn user rights for 12 healthcare professionals implicated in fraud and will surcharge facilities to recover any money paid through false claims.
Similarly, under Section 22 (4) and (5) of the Medical Practitioners and Dentists Council Act, CAP 253, facilities that operate without licenses or employ unregistered practitioners face fines of up to Sh10 million or jail terms of up to five years.
“Today’s submission of evidence to the DCI marks a critical next step in our fight against healthcare fraud. We have established a joint multi-agency investigation team, with officers from the DCI, Ministry of Health, SHA, KMPDC, and DHA. This team will work closely to ensure that all perpetrators—be they facilities, doctors, or patients—face the full force of the law,” Duale said.
“Let me be clear: as previously warned, any facility, doctor, or patient involved in fraud is now under the jurisdiction of our criminal justice system and will be prosecuted to the fullest extent of the law.”
He urged Kenyans to remain vigilant and support government efforts to eliminate fraud in the health sector.
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