The accusation is serious: in an outpatient care service, people in great need of care are said to have been cared for by staff who were not trained for this type of intensive care.
“Vital medicines were given incorrectly, blatant deficiencies in hygiene were accepted and services were billed for that were never provided,” says Dina Michels, chief investigator at the Kaufmännische Krankenkasse KKH, describing the consequences. The KKH, along with other health insurance companies, has therefore filed a criminal complaint; the damage amount is said to be in the millions.
The example is just one of many suspected cases that Michels and her team investigated over the past year to track down fraud in the healthcare sector. In its current report, the fund estimates the total damage caused by fraud, corruption or forgery of documents in 2023 to be around 3.5 million euros. This is one of the highest total damages since the Billing Manipulation Testing Group was started 23 years ago.
In the previous year, the cash register recorded damages of more than one million euros due to deliberate incorrect billing. According to the current report, outpatient care services caused the greatest damage at around 1.9 million euros, followed by pharmacies at around one million euros. In contrast, there were recourse claims from the fund against the accused services and practices amounting to 1.35 million euros.
The KKH is one of 96 statutory health insurance companies in Germany. The numbers she finds are just the tip of the iceberg. In the so-called misconduct report, which the umbrella association of statutory health insurance companies (GKV) regularly presents, the damage for the years 2020/2021 – more recent figures are not yet available – totaled 132 million euros nationwide.
However, according to experts, the number of unreported cases in this area is extremely high. According to estimates by the European network EHFCN, fraudsters divert around 56 billion euros from European healthcare systems every year. A study by the OECD from 2017 even speaks of six percent of annual health benefits in Europe that are lost to the system due to fraud.
The situation in nursing is particularly problematic. This is also reflected in the figures from KKH, which not only recorded the highest amount of damage last year, but also received the most evidence of possible billing manipulation.
The KKH announced that two thirds of the total of 553 new cases were caused by outpatient or inpatient care facilities. Physiotherapy and physiotherapy practices took third place.
The nursing sector, after all the third largest segment in the German healthcare system, has thus developed into a focal point. Overall, according to GKV estimates, statutory health insurance expenditure is likely to rise to 314 billion euros this year. “This makes some people want to get a piece of the billion-dollar healthcare system pie,” said KKH chief investigator Michels.
Although there are always only a few black sheep, they cause enormous damage to their respective professions and sometimes even endanger human lives in order to illegally collect large sums of money. This also includes the case of a pharmacist from Saxony who marketed underdosed cancer medications last year.
Even more problematic than the purely economic damage caused by such cases of fraud are the physical and mental consequences for patients and their relatives. “Such machinations lead to a loss of trust in the high-quality health care in our country,” warned Michels.
A Forsa survey commissioned by the KKH reflects this. According to this, 58 percent of Germans between the ages of 18 and 70 have already had experience with fraud in the healthcare system or know those affected.
For example, 41 percent of those surveyed stated that someone in their family or circle of friends was not receiving adequate care despite a recognized level of care, for example due to inadequately trained nursing staff or services not being provided.
In addition, one in four people knows at least one patient in their personal environment who was referred to a specific hospital by a specialist and was not able to go to the hospital of their choice.
These are also types of fraudulent behavior, according to the KKH. Overall, according to the survey, a clear majority of citizens (62 percent) consider the German healthcare system to be vulnerable to fraud and corruption.