There are few black sheep, but they cheat health insurance companies out of huge amounts of money – and harm people. They are unscrupulous, says KKH chief investigator Michels. One thing in particular stands out.

Many people are feeling the massive shortage of personnel in nursing. What is probably less known to most people is that the nursing sector is particularly prone to billing fraud and the use of pseudo-nurses.

There are a few fraudsters who act unscrupulously and sometimes endanger human lives in order to collect large sums of money illegally, said the chief investigator of the KKH Kaufmännische health insurance company, Dina Michels, on Wednesday.

The result: KKH alone, which is one of the largest statutory health insurance companies nationwide with more than 1.6 million insured people, suffered damage of around 3.5 million euros last year – the third highest annual amount to date. In 2022 the damage was more than one million euros, a year earlier it was 4.7 million euros.

Michels gave examples: “In an outpatient care service there is a suspicion that those in need of care were given intensive care by staff who were not trained for this. Essential medicines were given incorrectly, blatant deficiencies in hygiene were accepted and billing was also made for services that were never provided.”

The damage was in the millions. “But what is much more serious are the physical and mental consequences for those in need of care and their relatives,” she emphasized. Another case: A pharmacist from Saxony who is said to have dispensed cytostatics, i.e. cancer drugs, in underdosed quantities. The damage here is still unclear.

Last year, at the forefront of the suspects according to the health insurance company: outpatient care services with a loss total of around 1.9 million euros. This was followed by pharmacies with a good one million euros. In return, the fund recovered around 1.25 million euros with recourse claims – more than ever before. At the end of the year, a total of around 1,900 suspected cases were being processed, said Michels. The health insurance company filed criminal charges in 21 cases, primarily for fraud.

Whether billing for services not provided, the use of unqualified staff or fake prescriptions – in 2023 alone, 553 new reports of possible fraud were received nationwide, as the health insurance company announced. Mostly it was about outpatient (179 reports) and inpatient care (167), followed by physiotherapy and physiotherapy practices with 74 reports. In terms of regional distribution, North Rhine-Westphalia was in the lead with 128 reports – followed by Bavaria (76) and Baden-Württemberg (52). At the other end of the scale was Saarland with four cases.

But what attracts fraudsters to the healthcare system? The sums that flow into the system are, for many, unimaginably high. According to the health insurance fund, the service expenditure of the statutory health insurance companies was 274.2 billion euros in 2022 alone: ​​“This makes some people want to get a piece of the billion-dollar healthcare system pie,” said Michels, who is retiring at the end of May.

In fact, according to a Forsa survey commissioned by the KKH, 62 percent of people between the ages of 18 and 70 in Germany consider the German healthcare system to be vulnerable to fraud and corruption – 18 percent of them even classify it as “very vulnerable”.

For the survey, 1,004 people in this age group were interviewed nationwide from April 2nd to 5th. The health insurance company rated it as remarkable that 58 percent of those surveyed stated that they had already had experience with fraud in the healthcare system or knew those affected. Particularly striking again: the care sector. 41 percent of those surveyed said that someone in their family or circle of friends did not receive adequate care despite being awarded a level of care.

One in four people knows at least one patient in their area who was referred to a specific hospital by a specialist – i.e. could not go to the hospital of their choice. According to the survey, one in five people know of someone who has received bandages for their back or knees in the doctor’s office – or has experienced this themselves. According to the health insurance company, all of these cases are types of fraud that caused damage of around 132 million euros in the healthcare system in 2020 and 2021 alone.

According to Silke Kühlborn from the Leipzig public prosecutor’s office, head of a white-collar criminal law department with four departments to combat fraud and corruption in the healthcare system, more and more cases of fraud are being uncovered through meticulous investigative work: “It is shocking to see the criminal energy that the accused have “Some of their actions are revealed.” However, without specialized investigators from the law enforcement authorities, many cases of fraud are likely to remain undetected, she warned. It is striking that many fraudulent acts are not committed secretly. Employees usually know this – and are “surprised that it is accepted”. She called for efficient law enforcement.

One possible way to detect crimes in the future: the use of artificial intelligence. Michels explained that there was no other way to handle the “insane amounts of data”.