Crime scene healthcare! A billion-dollar fraud?
27.09.2022 10:42
The 16th Berlin Security Talks of the Association of German Criminal Police Officers (BDK) took place this year in cooperation with the National Association of Statutory Health Insurance Funds at the Bavarian representation in Berlin under the patronage of the Bavarian Interior Minister and Chairman of the “Standing Conference of the Interior Ministers and Senators of the States”. (IMK) instead. In addition to numerous representatives of law enforcement authorities, the event also attracted interest from health insurance employees.
On the podium, high-ranking representatives from politics, the judiciary and the criminal police discussed the current status quo in combating fraud and possible solutions with the BDK and the National Association of Statutory Health Insurance Funds. It became clear once again that effective prosecution of billing fraud and corruption in the healthcare system requires, above all, a larger number of specialist staff in the public prosecutor's office, criminal police and the statutory health insurance companies.
In his conclusion to the event, BDK federal chairman Dirk Peglow explained that “an effective fight against billing fraud in the healthcare system is only possible through the nationwide establishment of special services within the police and judicial investigative authorities. The fact that such special services have so far only been set up in seven federal states is shocking. The majority of my colleagues acquire the necessary specialist knowledge for these highly complex procedures on the side and often reach their limits. In addition to basic training and further education, we need IT equipment that can withstand the increasing digitalization of work processes in the healthcare system.”
Gernot Kiefer, deputy chairman of the National Association of Statutory Health Insurance Funds, emphasized: “In order to effectively combat fraud and corruption in the healthcare system, uniform, specialized investigative structures are needed across the country in all 16 federal states. No federal state can duck this! This is because specialized public prosecutors and specialized investigative groups are particularly effective and have proven themselves in the fight against billing fraud and corruption in the healthcare system. We therefore urgently appeal to the Conference of Interior Ministers to set up a federal-state working group to address this
“We must combat billing fraud in the healthcare system with great determination through criminal policy.”
Unfortunately, it is not only since the Corona pandemic that our healthcare system has offered sufficient opportunities to make criminal profits. According to estimates by the Federal Statistical Office, the pot from which the black sheep of all professional groups in the healthcare sector draw was filled with around 465 billion euros for 2021, thus reaching a new high in healthcare spending. A considerable sum, especially when you remember that the overall federal budget for 2021, including the supplementary budget, was approved at a total of 548 billion euros.
In addition to the desolate situation among the law enforcement authorities, the necessary importance is apparently not being attached to a survey of the amount of damage in Germany. At most, there are estimates based on a dark field study carried out by the University of Portsmouth in Great Britain. According to this, criminal acts are said to cause annual damage of around 6.19 percent of total health expenditure. Based on the service expenditure of statutory health insurance companies in 2021 amounting to 263 billion euros, this would be a sum of almost 16.28 billion euros that was obtained in Germany through financial crimes in the healthcare system.
Malpractice offices of the statutory health and nursing care insurance funds and the National Association of Statutory Health Insurance Funds
All statutory health and nursing care insurance funds and the GKV National Association have bodies to combat misconduct in the healthcare system (§§ 197a SGB V, 47a SGB XI). These investigative and audit bodies investigate information that points to “irregularities” or “illegal use of financial resources” in connection with the tasks of statutory health and nursing care insurance, in particular billing fraud and corruption. If the examination shows that there may be an initial suspicion of criminal acts with more than just minor significance for statutory health and nursing care insurance, the health and nursing care insurance companies should immediately inform the public prosecutor's office.