Apotheker cheats health insurance with HIV medicines?

A pharmacist in Berlin cheated health insurance companies with the help of HIV patients in the billing of drugs.

(12.11.2010) Pharmacist facilitates the statutory health insurance with the help of HIV-infected by more than 10 million euros, so the suspicion of the State Office of Criminal Investigation and the prosecutor's office in Berlin. On Wednesday and Thursday, the investigative authorities arrested the pharmacist and seven HIV-infected persons and searched their homes.

The State Office of Criminal Investigation (LKA) and the Berlin Public Prosecutor's Office have enforced eight arrest warrants and searched ten apartments nationwide on Wednesday and Thursday on suspicion of commercial billing fraud. A pharmacist and seven HIV-infected people should have facilitated the health insurance with the help of false billing of HIV medicines by millions. The investigation authorities speak of a damage incurred in the amount of about 10 million euros.

Pharmacist makes common cause with HIV-infected
The 66-year-old arrested pharmacist runs a pharmacy on the Kurfürstendamm in the Charlottenburg district of Berlin, which has been a point of contact for drug addicts for years. At the beginning nobody was surprised, that supposedly a lot of HIV-medications went over the counter. But between 2007 and 2009, the pharmacist with the help of those infected with HIV should have significantly improved his income. According to the findings of the investigating authorities, the Aids patients supported the suspected pharmacist's scam with a high level of criminal energy.

10 million damage to the health insurance companies
The also arrested HIV-infected would have a veritable „Medical tourism“ operated to get significantly more recipes from different doctors than they needed. Subsequently, the pharmacist had bought these recipes and billed at the coffers, without giving the appropriate medication to HIV patients, so the charge of the prosecutor's office Berlin. Due to the commercial and gang billing fraud with the average of 2,000 euro expensive prescriptions of HIV drugs, the statutory health insurance had incurred a damage of at least 10 million euros, the investigative authorities reported. How much of the illegally seized funds the doctor has passed on to the HIV-infected for the purchase of the recipes, the prosecutor's office did not want to communicate for tactical reasons.

Assured assets and prescriptions during house searches
The house searches carried out on Wednesday and Thursday in Berlin, Schleswig-Holstein and Hesse, were seized by the investigators in addition to assets of the accused pharmacist (several luxury cars and other valuables, total value over 200,000 euros) numerous recipes that occupy the commercial and gang billing fraud should. So goes the prosecutor's office Berlin „assume that now a large number of further investigations are initiated“ can, as their spokesman Martin Steltner in a joint press release by police and Attorney General Berlin emphasized.

Pharmacists and doctors generally enjoy great trust
Again and again, black sheep fall among the doctors and pharmacists with such fraudulent billing methods. For example, in recent days a Hamburg doctor has been arrested on suspicion of billing fraud. Since doctors and pharmacists have wide-ranging powers in the handling of medicines and their prescription as well as in the settlement of treatments, it is only too easy for persons with corresponding criminal energy to enrich themselves illegally in the system. No wonder that the association Berliner Apotheker e.V was therefore particularly shocked on Thursday, in view of the recent fraud case. „If the accusation is confirmed, we condemn the behavior in the strongest terms. We hope for an unreserved clarification of the facts“, stressed the club spokesman Jan Ott. Because the charge of commercial and gang billing fraud heavy relies on the confidence that the pharmacists generally enjoy the health insurance.

Routine checks would reveal accounting fraud
This confidence may also be one of the reasons why the current fraud has been noticed relatively late. Because normally it would be easy for the health insurance companies to check the data of their insured shortly to critical positions. At the billing offices of the injured health insurance companies, all relevant data are available and despite data protection regulations, the medical services would have to recognize the massive abuse when checking the insurance data.

In chronic diseases such as AIDS, only a certain amount of drugs is needed, the billed sums are much higher, abuse is very likely. But to detect such billing frauds, the insurance data would have to be checked regularly and this would require significantly more staff. So many health insurance companies rely on trustworthy behavior of doctors and pharmacists and control their data therefore only with occasional random samples. Sometimes a mistake, as it turns out now. For a loss amount of more than 10 million euros already requires a plethora of fake HIV medication bills (2,000 euros per billing = 5,000 fake bills with 10 million euros damage). (Fp)

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Picture credits: Jetti Kuhlemann