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Health insurers face several million euros of fraud damage every year because doctors make false bills, systematically misuse cards or submit fake prescriptions. The statutory health insurance company AOK Bavaria alone has reported over 60 million euros in fraud losses since 2004.
For example, a doctor has stolen around 1.2 million euros since 2004, reports Dominik Schirmer, AOK representative for combating misconduct. A former employee had reported that she should submit her and her family's health cards to the doctor - without anyone ever being sick. Or patients were enrolled in programs for the chronically ill without suffering from such an illness. "Since then we have not been able to get this doctor to behave in accordance with the rules," says Schirmer. And even then, not to withdraw access to the system from the doctor. A trial is still ongoing.
The AOK Bayern urgently sees a need for action to effectively combat misconduct in the healthcare system. Matthias Jena, Chairman of the Board of Directors of AOK Bayern, illustrates this using nursing as an example: "We require a nationwide central register that stores cases of fraud on a personal basis." So far, fraudsters could simply move on to a federal state and apply for a new license there without the health and long-term care insurance funds would be informed about the criminal career, says Jena. "Data protection must not be misused to protect the perpetrator." At the same time, Jena demands that the national associations of the nursing care funds are allowed to have police certificates of conduct issued by the owner of a nursing service, the senior nurse and her deputy. Jena would like to see considerably closer cooperation with the associations of nursing services in combating misconduct.
In total, the experts at AOK Bayern worked on more than 5,000 suspected misconduct cases in the healthcare system in 2014 and 2015 - including over 3,000 new cases and 2,100 existing cases. More than 3,400 cases were closed in the reporting period. In almost 400 cases, the AOK Bayern had activated the public prosecutor's office. Over 1,320 of the cases closed were classified as misconduct, around 270 cases were accounting errors. Overall, there was a need for criminal or civil / social law action in around 60 percent of the cases closed.
The total damage is 8.5 million euros. Bavaria's largest health insurance company has so far successfully reclaimed around 5.6 million euros. Since the misconduct agency was set up in 2004, AOK Bayern has identified total damage from fraud of over 60 million euros. More than 40 million euros were brought back.
Dr. sees positive Helmut Platzer, CEO of AOK Bavaria, the new Bavarian public prosecutors fraud in health care. "We are experiencing a constructive exchange." Platzer also welcomes the expansion of the responsibilities of these public prosecutors to all professional fields in the healthcare sector. “We are pleased that the Bavarian government has taken up our suggestions. This makes combating wrongdoing more effective - and also increases its deterrent effect. ”
Dominik Schirmer, representative for combating malpractice in health care at AOK Bayern, reports from the daily investigation: “The fraudsters are not just brazen and indecent. They are also becoming more and more professional. ”Schirmer says that targeted fraudulent care services would use electronic billing programs for their fraud. "But they then bill us - and that's unfortunately standard in nursing - on paper." Schirmer therefore calls for digital and tamper-proof billing systems in nursing. In the fight against fraud in the healthcare system, AOK Bayern uses intelligent software programs. “In the future, we want to use data mining to digitally check service providers' bills for fraud patterns,” says Schirmer. (sb)