Five directors linked to two healthcare providers have been charged after investigators uncovered an alleged scheme to siphon millions of shillings from the Social Health Authority (SHA) through fake medical claims, forged patient records and other irregular submissions.
The Directorate of Criminal Investigations (DCI) on Tuesday presented the five before the Milimani Law Courts following investigations into alleged fraudulent claims made by Nissi Medical Centre and Dawa Front Healthcare Services.
The case stems from a complaint filed by the Social Health Authority, which prompted investigations and a forensic audit into claims submitted by several healthcare facilities contracted under the public health insurance programme.
According to the DCI, the audit uncovered widespread irregularities in the claims process and further established that some health facilities that had previously been closed by the Kenya Medical Practitioners and Dentists Council (KMPDC) for failing to meet regulatory requirements were still operating under active SHA contracts.
Investigators say the suspects coordinated a scheme involving fake medical claims, including billing for patients who were never admitted, falsified treatment records and false information used to obtain payments from the public health insurer.
"Subsequent investigations established that the suspects allegedly orchestrated fraudulent schemes involving irregular and fictitious medical claims, including claims for patients who were never admitted, falsified medical records, and false statements made to obtain payments from SHA," the DCI said in a statement.
Detectives allege that Nissi Medical Centre received more than Sh38.7 million through the suspected fraudulent claims, while Dawa Front Healthcare Services is said to have obtained more than Sh2.5 million. Authorities also said they stopped additional suspected fraudulent claims worth over Sh8.1 million before any payments could be made.
Those charged are Nissi Medical Centre directors Dominic Atieno and Peter Atieno, as well as Dawa Front Healthcare Services directors Eugine Ochieng, Enos Osire and Elija Otieno.
The five face charges of conspiracy to commit a felony, making false statements to obtain benefits under the Social Health Insurance Act, and acquisition and use of proceeds of crime contrary to the Proceeds of Crime and Anti-Money Laundering Act (POCAMLA).
The DCI said investigations are still ongoing, with detectives pursuing other suspects believed to have been involved in the alleged fraud.
"The DCI remains steadfast in protecting public resources and ensuring that individuals who exploit public health financing systems through fraud are brought to justice in accordance with the law," the agency said.