AOK Bayern reveals millions of dollars in damages due to fraud

The health insurance companies have to suffer several million euros of fraud each year, because doctors make false statements, systematically operated card fraud or fake prescriptions are submitted. Only the statutory health insurance AOK Bayern reported more than 60 million euros loss by fraud since 2004.

For example, a doctor since 2004 has struck around 1.2 million euros, reports Dominik Schirmer, AOK representative for the fight against misconduct. A former employee reported that she should submit her and her family's health cards to the doctor - without anyone ever being ill. Or patients have been enrolled in programs for the chronically ill, without them suffering from such a disease. "Since then, we have not been able to bring this doctor to compliant behavior," says Schirmer. And even then not to deprive the doctor of access to the system. One procedure is still going on.

Only the AOK Bayern complains 60 million loss by cash fraud. Image: Renars2014 - fotolia

The AOK Bavaria sees urgent need for action to effectively combat malpractice in health care. Matthias Jena, chairman of the board of directors of the AOK Bavaria, illustrates this with the example of care: "We demand a nationwide central register, which stores cases of personal fraud." Previously, fraudsters could simply move on to one federal state and apply for a new authorization there without the health and long-term care funds would be informed about the criminal career, says Jena. "Data protection must not be abused as perpetrator protection." Jena also demands that the state associations of the long-term care funds are allowed to submit police certificates of guilt from the owner of a nursing service, the senior caregiver and their deputy. Jena wishes to work much more closely with the associations of the care services in the fight against misconduct.

In total, the experts of the AOK Bavaria processed more than 5,000 suspected cases of misconduct in the health care system in 2014 and 2015 - including more than 3,000 new cases and 2,100 existing cases. More than 3,400 cases were completed during the reporting period. In just under 400 cases, the AOK Bayern had turned on the prosecutor. More than 1,320 of the completed cases were classified as misconduct, around 270 cases were billing errors. All in all, about 60 percent of completed cases required criminal or civil / social action.

The total damage is 8.5 million euros. Bavaria's largest health insurance company has so far been able to reclaim around 5.6 million euros. Since establishment of the misdemeanor place 2004 the AOK Bavaria a total damage by fraud of over 60 million euro determined. Over 40 million euros could be brought back.

Positive sees Dr. Helmut Platzer, CEO of AOK Bayern, the new Bavarian public prosecutor's office scams in healthcare. "We are experiencing a constructive exchange." Platzer also welcomes the extension of the jurisdiction of these public prosecutor's offices to all health care professions. "We are pleased that the Bavarian State Government has taken up our proposals. This makes the fight against misconduct more effective - and also the deterrent effect. "

Dominik Schirmer, Commissioner for Combating Misconduct in Health Care at the AOK Bayern, reports from the daily investigative work: "The fraudsters are not only bold and indecent. They are also getting more and more professional. "According to Schirmer, fraudulent care services would use electronic billing programs for their scams. "However, they then count on us - and this is unfortunately the standard in care - on paper." Schirmer therefore demands digital and tamper-proof accounting systems in nursing. In the fight against healthcare fraud, AOK Bayern relies on intelligent software programs. "In the future, we want to use data mining to digitally check the billing of service providers for fraud patterns," says Schirmer. (Sb)