# What fraud controls should a clinic's billing and claims team have?

URL: https://tymirahealth.com/resources/faqs/what-fraud-controls-should-a-clinic-s-billing-and-claims-team-have
For: Finance | Clinic operations | Reviewed by Independent clinical reviewer, Registered mental health clinician, Kenya | Last reviewed 8 November 2026

**Answer:** Separate duties: different people should register patients, record services, submit claims and reconcile payments. Use M-Pesa's maker-checker roles for reversals and transfers, and never collect payments on personal phones. Reconcile claims to appointment and attendance records. SHA's contract defines fraud to include claims for services not given, ghost patients and falsified records, bans practices such as unbundling, and requires providers to report suspected fraud within 24 hours. Review unusual patterns monthly, such as repeat claims or out-of-hours sessions.

Sources: Social Health Authority: https://www.sha.go.ke/wp-content/uploads/2026/09/PART-A-Master-General-Terms-Conditions.pdf - Social Health Authority: https://new.sha.go.ke/wp-content/uploads/2026/09/PART-B2-Social-Health-Insurance-Fund-Contract.pdf - Safaricom: https://www.safaricom.co.ke/main-mpesa/m-pesa-for-you/helpful-m-pesa-channels/m-pesa-super-app-and-mini-apps

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