The Social Health Authority (SHA) has sent shockwaves across the healthcare sector after flagging claims worth more than Ksh 3 billion. Hospitals now have just 15 days to justify these claims or risk automatic rejection.
The flagged claims, according to SHA, were mostly incomplete and lacked critical documents. In response, the Authority has introduced a new digital resubmission module to tighten loopholes, curb fraud, and enhance transparency. This move signals a new era of accountability in Kenya’s healthcare financing.
SHA Flagging Triggers New Digital System
On Monday, September 15, SHA announced that more than Ksh 3 billion worth of hospital claims had been flagged. The primary issue was missing documentation, including itemised invoices, discharge summaries, and completed claim forms. Without these, the claims could not be verified.
SHA CEO Mercy Mwangangi stressed that the exercise was part of routine adjudication and not a one-off crackdown. She explained that claims without proper documentation undermine accountability and expose the healthcare system to fraud.
To counter this, SHA unveiled a new digital process starting September 16. A Missing Documents Resubmission Module has been activated on the provider portal. Hospitals will now be able to respond directly within the system, making corrections easier while ensuring no records are tampered with.
Once flagged, hospitals will have 14 days to upload the required documents. A countdown timer will track the deadline for each claim, visible on the system dashboard. Patients will also be notified about their claims, a move aimed at keeping them in the loop and building trust.
If providers fail to act within the set period, their claims will be automatically rejected. SHA has set September 30 as the final cut-off date, meaning hospitals have just weeks to clean up their records or lose billions in pending claims.
Hospitals Under Pressure to Comply
The new rules place hospitals under immense pressure. In the past, providers could resubmit claims without a strict timeframe, creating a backlog and delaying payments. Now, the 14-day rule changes everything.
Hospitals will no longer have the option of replacing previously uploaded documents. The system will only allow additional files to be added in line with SHA notes. This preserves the integrity of the original submission and prevents manipulation of records.
For many hospitals, especially those with large patient volumes, the timeline will test their administrative systems. Compliance officers must now streamline internal processes to meet the Authority’s deadlines. Failure to act will not just affect finances but could also damage reputations in an already competitive sector.
Transparency and Routine Checks
SHA has made it clear that the changes are part of a broader strategy to increase transparency in healthcare funding. By directly involving patients through notifications, the Authority is empowering them to follow up on claims in real-time. This approach reduces the risk of fraud and helps patients understand the status of their cases.
The Authority has also announced fresh surveillance efforts. County health teams will begin routine inspections from September 16. Hospitals are expected to cooperate fully with these teams, which will monitor compliance and identify loopholes on the ground.
To make the transition smoother, SHA has uploaded a step-by-step guide on its official portal. This manual details how providers can use the new system and avoid costly mistakes.
In the bigger picture, SHA’s reforms mark a bold attempt to clean up a healthcare system plagued by inefficiencies. Flagging over Ksh 3 billion worth of claims is a clear warning that incomplete paperwork and questionable submissions will no longer pass unchecked.
