Ivan Tomka (36) has a passion: The Manager of data forensics, the health insurer Helsana for his life like the needle in the haystack. The haystack, the the 170 million invoice items, the process the health insurance company Helsana, every year – and control – must.

The plug-in needle, which are abnormalities in the individual bills that can provide information on the fraudulent behavior of the fat-cat Doctors. Black sheep of their craft, the cash for their medical services more than they are entitled to.

The health expert Felix Schneuwly (58) from the comparison service Comparis damage “rip-off” Doctors, estimates the total at 80 million francs, and this, in itself, to the detriment of the basic insurance. At the end need to pay for the premium payer.

The wants to put Tomka of the Helsana, it has a bar. “When we talk about fraud and abuse in health care, then there are usually providers behind it. Especially Doctors, but also hospitals, pharmacies or laboratories,” says Tomka. He is not looking for the individual cases, but tries, the systematic fraud. “These are the cases that go right to the money.”

specialists in the sights

For example, in the widespread Operation against the grey Star. At the time of their settlement, some of the eyes from cash doctors powerful. Many operations per year, an intervention that takes place largely after the same pattern, and a medical lens implant, which can cost a few Hundred francs: a pattern that helps the data detective to uncover fraud. “These properties not only apply in the case of medical interventions,” says Tomka. Other specialist groups are in his sights. He does not want to reveal.

The Swiss specialist society for eye physicians white the black sheep in your Guild. “Most of all in Switzerland make eye doctors pay is correct,” says administration Secretary Harald Grossmann (55) on request of a VIEW. “We take the issue very seriously. In August, we will be holding our conference for this purpose, a Workshop on the topic of proper billing.”

In the hunt for the rip-off Doctors Tomka has teamed up with the professional Association of eye doctors. This provides the insurance detectives with Details about individual operations. The cooperation will lead to fair and affordable prices for the premium payer. “And useless addition prevents payments for the patient.”

Tomka reported by a sample case of so-called discount Laundry, he came on the track. This relates to an eye clinic in the Zurich area. The damage alone for the premium payer of the Helsana: around 1.5 million Swiss francs. Over all the basic insurance over the premium payer, should have been ripped off by these eye clinic of 7.5 million Swiss francs.

Tomka and his Team have also managed to attract regular irregularities. The “needle” is a particular type of lens. This was offset by the eye clinic more expensive than usual. This can happen in individual cases, however, Helsana recognized the System behind it.

The battle against the rip-off Doctors is worth it

Since these lenses are shopped on a large scale, there is often a price discount. Only, this reduction in costs to the patient or the funds. The eye clinic had to charge an “advanced suppliers” for the lenses of an “desire price”, as Tomka calls it. The difference landed in the eye clinic, not the patient. A view into the commercial register shows that: – The supplier also belongs to the eye clinic group.

The damage the clinic has not yet been paid, but the pressure of Helsana effect. “In the meantime, the clinic will charge a fee for this eye surgery, to correct prices,” said Thomka.

thanks to Helsana blown by a group practice in Geneva, over the years, Doctors have billed that were not approved for the basic insurance. The Canton of Geneva, knows of an approval stop for Doctors in the basic health insurance. The Damage: 2.3 Million Swiss Francs.

Also a popular pattern: Bschiss with the journey flat rate. Doctors treat a whole day of patients at the same address, for example, in a nursing home. However, the health insurance charge, the smart guy, the Outward and return journey for each patient individually. The data analysis in a matter of seconds the doctor, address and work day.

The statistics of cosmetics is another pattern. The Helsana, a family physician and the rheumatologist is not noticed come out, has tried to, in the case of the performance audit. The resourceful doctor has lowered the average cost of its most expensive patients, by andrehte family members, unnecessary petty investigations. Advantage: The Oversupply of its most lucrative patients thus nothing in the way. Paid by the premium payers!

Around ten million Swiss francs abgezockter money wants to get back Tomka this year. Doesn’t sound like much. However, he is convinced that due to his work, dozens of millions more are saved by deterrence: “It is like a lightning box. The Assembly causes the majority of drivers, the correct speed to be maintained. The other is to be flashed.”

other funds are called the shenanigans on the track: The CSS, the most sick requires insurers back in the country, in the last year, six million Swiss francs, of fraudulent Doctors, on request. This year it will be even more than ten million Swiss francs.

each year, around 100’000 people their eye surgery because of cataract. The clouded natural lens is replaced by an artificial one. But the price for this artificial lens eyes try to cheat the doctors ever again.

Not only for the health insurance, but also for the patients it means: look closely! Because single black sheep among the ophthalmologists, the package price for this surgery, Hiking to “under”, as Ivan Tomka (36) warns of Helsana.

This means that it would be required for the alleged additional services such as “comfort anesthesia, normal aspheric lenses, UV Filter lens, or the like” co-payments of several Hundred francs per eye. The can do the surgery quickly to 1000 francs more expensive. Money that you must shell out the Patient from the bag.

These additional payments were, firstly, from collective legal point of view, is questionable, says Tomka. “Because the co-payment would constitute a real added value. And secondly, the maximum is unfair to the patient, because the physician uses his knowledge to the advantage shamelessly for your own wallet.”

However, patients can prevent: Tomka recommends a free offer in a second eye doctor obtain. In addition, the magazine “observer” leads a list of eye doctors that perform the surgery at no extra cost and at fair prices.