Billing fraud

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Billing fraud is a collective term for special forms of fraud in the German health care system where doctors , psychotherapists , dentists , hospitals or other service providers such as speech therapists , physiotherapists , occupational therapists or outpatient care services obtain remuneration for services not provided or from pharmacists , medical supply stores or others Service providers of the supply of medical aids collect reimbursements for deliveries that have not been made by means of deception. Billing fraud can also exist if a service is provided but a higher-quality service is billed.

In addition to one service provider, patients or health insurance employees or several service providers (e.g. doctor and pharmacist) can also be involved in billing fraud .

Situation in Germany

In recent years the number of investigative proceedings in this regard has increased in Germany . Official statistics show 13,781 cases for 2003, 1374 more than in 2002.

From the middle of 2014, a wave of investigations against outpatient care services broke out. In Berlin, almost every fourth nursing service is currently affected by the investigations by the LKA 195 and the public prosecutor's office.

Effects

Who is the victim of billing fraud in the healthcare sector depends on the respective service area due to different remuneration systems.

Through billing fraud with budgeted services of contractual (dental) medical or contractual psychotherapeutic treatments, contractual (dental) doctors and contractual psychotherapists damage their specialist colleagues in the same statutory (dental) medical association (KV or KZV), whose point values ​​and fees are therefore lower. The reason for this is that the health insurance companies pay a lump sum (the so-called total remuneration ) to the (dental) medical associations for the remuneration of the contractual (dental) medical or contractual psychotherapeutic services . The KVs or KZVs then distribute the money from this “budget” to the billing contract (dental) doctors or contract psychotherapists. If the total remuneration is not sufficient to fully remunerate each service invoiced in the sense of an individual service remuneration, the deficiency will be compensated for through fee reductions as part of the fee distribution to the participating contract (dental) doctors or contract psychotherapists. Incorrect billing by individuals reduces the total remuneration, which can ultimately lead to lower fee payments to the other contract (dental) doctors or contract psychotherapists.

In contrast to the incorrect billing of budgeted contractual (dental) medical services, incorrect billing of private services or non-budgeted contractual (dental) medical or contractual psychotherapeutic services by (dental) doctors, psychotherapists and other service providers such as medical supply stores, physiotherapists, outpatient care services, Pharmacies and members of other health professions cover the full amount of the damage to the respective cost bearer. This is usually the health insurance company , the private health insurance company or the patient's subsidy provider , other payers or the self-paying consumer or patient .

Which contractual (dental) medical or contractual psychotherapeutic services are budgeted and which are not, results from the fifth book of the Social Security Code (SGB V) and, if applicable, from the overall contracts agreed by the relevant K (Z) V with the respective health insurers (so-called remuneration agreements ).

Billing fraud by hospitals (e.g. due to the inappropriate choice of disease codes (e.g. upcoding ) or incorrect use of public funds) is rarely discussed in relation to its economic importance.

Measures to combat

The fight against billing manipulation by the institutions of the statutory health insurance is anchored in law. According to § 197a SGB ​​V, every health insurance company and according to § 81a SGB ​​V every association of statutory health insurance physicians has to set up a body to combat misconduct in the health care system, which has to investigate information about possible illegal or improper use of funds in their respective area of ​​responsibility and, if necessary, to inform the public prosecutor's office .

The task of checking the correctness of the fee bills of contract physicians and contract dentists lies in accordance with Section 106a (1) SGB V with the (dental) medical associations and the health insurance companies. The (dental) medical associations also use a number of plausibility checks, such as For example, a check of the plausibility times introduced with the EBM 2000plus , in which a minimum required time is determined for individual services, so that it is noticed promptly if the total of these times exceeds a plausible value (e.g. 12 hours) by the doctor or psychotherapist per day). Other anomalies of a billing can be uncovered by reports from contract experts or the medical service of the health insurance . The knowledge gained from this can provide information about the existence of a billing fraud and prompt the named bodies to inform the public prosecutor's office.

In addition to the criminal law assessment, a culpable incorrect billing by the contracted (dental) doctor or contract psychotherapist is assessed as a contractual (dental) medical or contract psychotherapeutic breach of duty, leading to the imposition of a disciplinary measure by the (dental) medical association up to the withdrawal of its approval by can lead the admissions committee .

In addition to the offices set up at the health insurance companies and (dental) medical associations, some health insurance companies have also organized themselves in associations or working groups in order to specifically counteract information. In addition to the various regional health insurance associations, the following organizations have been set up:

  • argab - Working Group Against Billing Fraud -

This working group was founded by 5 company health insurance funds to jointly combat misconduct in the healthcare system in July 2008. 23 health insurances are currently working together in order to jointly investigate clues and to better combat such misconduct.

  • ÜdaV (monitoring of billing contract partners)

The following members: AOK Lower Saxony, several company and guild funds, the Knappschaft and Landwirtschaftliche Krankenkasse. This organization is mainly active in Lower Saxony.

Billing fraud by (dental) doctors and psychotherapists

In Germany, the services that have been provided for a person insured in the statutory health insurance are recorded by the contract (dental) doctor himself and transmitted to the statutory (dental) medical association responsible for him. The billing data is anonymized and forwarded to the responsible health insurances by the Association of Statutory Health Insurance Physicians. On request, the patient will receive information on services and costs ( patient receipt ); however, experience shows that such receipts are rarely actually required. In addition, the contract (dental) doctor or contract psychotherapist does not yet even know what value the points that he can charge for it will have as a specific amount of money when the service is provided; so he cannot issue a confirmation with a specific amount of money for it. The control of the accounts is possible via random samples, plausibility checks and statistical methods.

Examples of billing fraud are:

  • billing of services not provided (so-called "air services")
  • Incorrect billing of services (excessive services or incorrect classification)
  • Billing of services not provided personally (example: an employed clinician performs a service and the chief physician bills this as a personal service provided himself)
  • Billing on the wrong date; the doctor thus avoids exclusion of benefits or maximum amount regulations.

Examples of billing fraud by pharmacists and other service providers

The possible variants of billing fraud involving pharmacists and other service providers are diverse.

Examples of billing fraud by pharmacists are:

  • Dispensing of reimported drugs or imitation drugs ( generics ) with the calculation of the original drug
  • Billing of recipes that are not supplied

Forms for billing fraud involving third parties:

  • Pharmacists or suppliers pay the prescribing doctors a commission ( allocation for a fee )
  • Pharmacists or suppliers share the deceived amount with the patient if part of the prescription is not issued and the health insurance company is fully billed or exchange prescriptions for other goods (cosmetics, sexual enhancers, other non-prescription preparations, etc.).

The prescriptions of doctors are regulated by budgets, so that a doctor is personally liable (with his own assets) for the profitability of his prescriptions. When checking the prescriptions of a doctor, incorrect billing from pharmacies is occasionally uncovered.

Billing manipulation by physiotherapists:

  • Provision of services for which the treating physiotherapist is not qualified (services that are not billable due to a lack of proof of qualification)
  • Billing of services not provided, e.g. In some cases including falsification of the insured's signature on the back of the drug ordinance
  • Billing of treatments other than those actually provided. Here, partly in cooperation with the insured person, a medically prescribed service (e.g. physiotherapy) is exchanged for another (e.g. massages). In contrast, the prescribed and possibly more expensive service is acknowledged.

Opportunities for billing fraud by outpatient care services:

  • Billing of services not provided, possibly including forgery of signature on the performance record.
  • Billing of services that were provided by unskilled personnel.

In addition to the examples mentioned, there are a number of other possible billing manipulations that can be punishable as fraud:

  • Obtaining benefits from patients when using electronic health cards (health insurance cards) from third parties
  • Settlement of services for deceased persons whose health card was kept in the practice and routinely scanned
  • Double invoicing of services via different factoring companies .
  • Obtaining sick leave from patients

Examples of billing fraud by outpatient care units

According to Section 263 of the Criminal Code, accusations of fraud in the care sector are possible in many ways. The main accusation is that services not provided were still billed. In some cases, these are said to have been repeatedly and permanently incorrectly initiated.

For this purpose, the outpatient care services should have given specific instructions in order to obtain additional care subsidies. Essentially, an increased need for care is simulated by the previously trained behavior of the person supposedly in need of care. As a precaution, the apartment is equipped with a rollator, bathtub lift and even diapers.

Not only can the nursing services make themselves liable to prosecution according to § 263 StGB, but also the patients. By means of so-called kick-back payments , the supposedly in need of care should also have been "reimbursed" to the extent of the care services not provided by repayments from the outpatient care units.

The penalty is usually particularly drastic in the context of billing fraud. Each accounting period is assessed by the public prosecutor as a legally independent act. One patient a year can quickly result in fraud in at least twelve cases. As so-called commercial fraud, this particularly serious case is threatened with at least six months' imprisonment (Section 263 (3) No. 1 StGB).

If the investigating authorities suspect that the managing director and the nursing service have cooperated with the patient, the suspicion of commercial fraud as a member of a gang quickly arises. This alternative, which is more punishable under Section 263 (5) of the Criminal Code, is threatened with at least one year imprisonment.

Healthcare billing fraud literature

  • Franz-Josef Dahm, Jens Schmidt: Incorrect accounting (accounting fraud). In: Hans-Jürgen Rieger, Franz-Josef Dahm, Gernot Steinhilper (ed.): Lexicon of medical law. 2nd, completely revised and expanded edition, loose-leaf edition. Müller, Heidelberg 2001-2007, ISBN 3-8114-2228-6 , article 1780 (32 pages).
  • Uwe Hellmann, Harro Herffs: The medical accounting fraud. Springer, Berlin et al. 2006, ISBN 3-540-25691-1 .
  • Harro Herffs: The billing fraud of the contract doctor (= MedR, series of medical law ). Springer, Berlin et al. 2001, ISBN 3-540-42711-2 (also: Potsdam, Universität, Dissertation, 2001).
  • Heike Hancok: Billing fraud by contract doctors (= health law and health sciences. Vol. 15). Nomos, Baden-Baden 2006, ISBN 3-8329-2243-1 (also: Tübingen, University, dissertation, 2005/2006).
  • Hendrik Schneider , Claudia Reich: Billing fraud through "upcoding". A contribution to the case groups of "implied deception" in the criminal offense of fraud. In: HRRS. Issue 6, 2012, ISSN  1865-6277 , pp. 267-272.
  • Jan C. Schuhr : StGB §§ 263, 263a. In: Andreas Spickhoff (Hrsg.): Medizinrecht (= Beck's short comments. Vol. 54). Beck, Munich 2011, ISBN 978-3-406-59382-6 , pp. 2206-2233.
  • Gernot Steinhilper (Ed.): Doctor and billing fraud. Legal questions about the investigation procedure (= Kriminologische Schriftenreihe der Deutschen Kriminologische Gesellschaft eV, Vol. 95). Kriminalistik-Verlag, Heidelberg 1988, ISBN 3-7832-0388-0 .
  • Gernot Steinhilper: Criminogenic Norms? Criminal policy considerations to curb medical billing fraud. In: Thomas Feltes , Christian Pfeiffer , Gernot Steinhilper (ed.): Criminal policy and its scientific basis. Festschrift for Professor Dr. Hans-Dieter Schwind on his 70th birthday. Müller, Heidelberg 2006, ISBN 3-8114-5241-X , pp. 163-174.
  • Gernot Steinhilper, plausibility checks and suspected fraud among contract physicians - procedural regulations of the statutory health insurance associations. In: Arbeitsgemeinschaft Medizinrecht (Ed.): Plausibility check, legal issues of group practice, accounting manipulations (= series of publications of the Arbeitsgemeinschaft Medizinrecht im DAV. Vol. 5). Alma Mater, Saarbrücken 2005, ISBN 3-935009-13-5 , pp. 285-298.
  • Klaus Ulsenheimer : The contract doctor as administrator of the property interests of the statutory health insurance? In: Medical Law. Vol. 23, No. 11, 2005, ISSN  0723-8886 , pp. 622-628, doi: 10.1007 / s00350-005-1527-0 .
  • Rüdiger Weidhaas: The medical doctor between fraud and infidelity. In: Journal for the entire medical and health law. Vol. 3, 2005, ISSN  1612-734X , pp. 52-55.

Web links

Individual evidence

  1. ^ H. Schneider, C. Reich, billing fraud through "Upcoding" , HRRS , ISSN  1865-6277
  2. ↑ Sebastian Braun: The medical accounting fraud . ( zjs online )