UClean deals for masks, bills for corona tests that never existed, corona aid that was given without cause, and finally the suspicion that some state-subsidized intensive care beds actually never came about – fighting the pandemic doesn’t just cost many Billion euro. Billing fraud and corruption trickle away billions without having any effect on patients or those affected.
This is the conclusion reached by the National Association of Statutory Health Insurance Funds (GKV) and the experts from the auditing firm PWC who specialize in crime in the health sector.
The auditors had already determined on the basis of the numbers up to the outbreak of Corona at the beginning of 2020 that fraudsters are causing immense damage in the German health sector. “Billing fraud leads to billions of euros in damage to statutory and private health insurances every year – for which the insured ultimately have to pay,” was the conclusion of the PWC study on the subject.
“Compared to our first analysis from 2012, we can see a significant increase in billing fraud offenses. And what we capture is only a part. The dark field is huge, ”says PWC partner and forensic scientist Gunter Lescher WELT. “The number of cases of fraud is likely to have increased significantly again with the corona pandemic.” According to the assessment of the representatives of the statutory health insurance, the financial damage as a result of the pandemic due to fraud and unintentional incorrect billing has increased massively.
“Many interfaces that can become weak points”
Billions are pumped into the German healthcare system every year, it is one of the most recognized in the world – but also one of the most expensive systems. Health expenditure in Germany in 2019 was 411 billion euros. That is 4944 euros per inhabitant and corresponds to a share of the gross domestic product of 11.9 percent. Statutory health insurance accounts for more than half of the expenditure (57 percent).
These sums attract fraudsters. “The health sector is particularly susceptible to fraud and corruption,” says forensic scientist Lescher. “The system is complex, there is a lot of money involved, and there are many interfaces with the many parties involved, such as service providers, insurers and billing service providers, which can become weak points.”
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Hospitals and Corona – – – – –
Even before the corona pandemic, according to the PWC survey in 2019 and 2020, more than half of the statutory health insurers reported at least 100 cases of fraud a year with a total loss of mostly more than 500,000 euros. Three quarters of the private health insurance companies reported total damage of more than 500,000 euros due to billing fraud – in both cases significant increases compared to the year of the first study in 2012.
With the outbreak of Corona, many more billions flowed to contain the pandemic, which, according to the experts, naturally increases the number of cases of fraud and the resulting damage. “The reasons for this are varied, existential difficulties, high pressure on those responsible to deliver good figures even in times of pandemic, but above all too few controls,” says Lescher.
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It is understandable that in exceptional situations you have to react quickly and also find unconventional solutions in order to master a challenge like Corona. “What was achieved there should be expressly recognized. But it can’t be at the expense of spending reviews – and that’s it. The test procedures must be sharpened significantly, ”demands the PWC expert for white-collar crime.
PWC had repeatedly criticized the fact that the statutory health insurance funds did not pursue suspected cases sustainably enough. The willingness to investigate evidence of criminal activities from outside has “noticeably decreased”, according to the latest report by the auditors. And that despite increasing attempts at fraud. Only a little more than half of the health insurers surveyed stated that they “consistently followed up information”.
Control options reduced by law
One reason for this, however, is the requirements of the federal government. In the area of hospitals, for example, it ensured that the number of accounting controls by the cash registers had to be reduced significantly.
Before the outbreak of the pandemic, the statutory health insurance companies checked an average of 17 percent of all bills submitted by the clinics on a random basis. If the so-called plausibility checks, during which the data was checked by computer systems, revealed abnormalities, follow-up checks were initiated. It regularly turned out that, on average, every second hospital billing was incorrect, i.e. excessive. Partly due to fraud, but most of the time as a result of non-deliberate errors.
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These examinations flushed many millions of euros back into the statutory coffers, which were then available again for the members. At the end of 2019, however, a maximum permissible inspection rate was introduced for 2020 and set at 12.5 percent. A few weeks later, the Hospital Relief Act reduced the maximum permissible inspection rate from 12.5 percent to five percent. This also applied retrospectively to the first quarter of 2020.
So even though there is more money available and more opportunities for fraudsters, the possibilities of control have been limited by law. “The reduction of the inspection rate to five percent costs our contributors an estimated two billion euros per year,” says a spokesman for the umbrella association of statutory health insurance companies. So much escapes the funds from additional demands that result from the reviews.
There is still no clear picture of intensive care beds
Reducing controls and thus relieving staff fighting against Corona of bureaucracy is understandable. On the other hand, this decision is explosive in view of the many unanswered questions about the correct use of membership fees and tax revenues in the pandemic. For example with the intensive care beds.
For weeks there has been discussion about whether beds that have been subsidized have actually been set up. The GKV lamentsthat at least 2000 beds “disappeared” for which there was money from the health fund, into which the insured and the federal government pay.
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Corona and hospitals – – – – –
The hospitals reject the allegation, but the GKV has not yet been able to prove it – because there are no controls and therefore no overview. The federal states would be responsible for this, as they are responsible for investing in hospital infrastructure. But so far “no abnormalities” have been found, the health ministries of several countries said on request.
“There is currently a lot of speculation about possible cases of fraud in the billing of intensive care beds, but there is no clear picture. Those involved, health insurers, clinics and politicians now have to deal with this, ”demands PWC partner Lescher. “The bills must be carefully analyzed together with the legal framework when setting up the beds. As far as I understand, this has not yet been done. But this is necessary to end the discussion and to create clarity. “
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