Health Cabinet Secretary (CS) Aden Duale explained the reasons why the Social Health Authority (SHA) rejects certain claims.

Appearing before the Senate, Duale said some claims are rejected because they do not have claim forms.

“The law you passed here, at the bottom, there was a claim form. A claim form is a legal document. If a facility has not provided a claim form when they are asking for a reimbursement, that becomes an automatic rejection,” Duale said.

Duale said SHA also rejects claims if the facility has provided an itemized invoice.

He said claims with no discharge summaries are also rejected.

“If you do not give us a discharge summary on when the patient has left, that is a rejected claim,” he said.

Additionally, Duale said claims are also rejected when there is no supportive theatre.

“If a Kenyan citizen, who is a member of SHA, goes to a theatre, for any type of procedure, and you make the claim to SHA for reimbursement, and you have not attached theatre notes, that is a rejected claim, and we will not pay,” he added.

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SHA Delivery Claims

Duale said SHA does not pay for delivery claims with a birth notification.

“If a delivery has taken place in any health facility, the mandatory document is a birth notification.  If you want us to pay for your delivery, whether normal or cesarean, and a birth notification is missing, we will not pay you because we cannot confirm whether the child has been born,” Duale said.

Further, he said the SHA system also picks upcoding incidents where facilities claim to do complicated procedures when in reality they do not.

He said such claims are rejected and SHA does not pay.

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Outpatients to Inpatients Fraud

Besides, Duale said SHA does not pay facilities claims that turn outpatients into inpatients.

“If you convert outpatients to inpatients, that is the biggest fraud. There are Kenyans who go, they are treated, they go home, then the facility turns them into inpatients because they want to claim the bed, they want five days,” Duale said.

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A picture of SHA Office in Nairobi
Photo/SHA Website