Bavaria: Investigations into fraud in the healthcare sector – Bavaria

There is the example of a resident doctor who is said to have personally read the insurance cards of his patients into the computer. According to the public prosecutor’s office, to manipulate the date and bill fake practice visits to health insurance companies. Doctor appointments that never happened. The doctor is said to have practiced this scam for at least six years. Presumed damage: more than three million euros. It was blown because he often asked the health insurance companies whether certain patients were still insured there. In any case, a cash register clerk was taken aback.

That’s how “the ball started rolling,” says senior public prosecutor Richard Findl, speaking of a “very clear case of fraud.” He heads the Bavarian Central Office for Combating Fraud and Corruption in the Healthcare System, ZKG for short. The special unit is based at the Attorney General’s Office in Nuremberg and has not only filed charges in this matter. Findl, he is basically Bavaria’s top investigator in the healthcare industry, sees a problem in the system in this case. A patient only knows his treatment; but not what the practice settles with the cash registers. And the cash registers only know what they are billed for; but not what actually happened in the doctor’s office. It was precisely into this “gap” that the accused doctor had come.

Findl can tell a lot about the black sheep in the healthcare system and their tricks. The energetic lawyer previously investigated hundreds of cases against suspected criminals in medical practices, pharmacies or nursing services at the Munich I public prosecutor’s office. The Munich office used to be one of three main public prosecutor’s offices in Bavaria, from which the ZKG emerged. Findl warned years ago that what was being determined was only the “tip of the iceberg”. The complicated healthcare system invites fraud.

Now he and his team are systematically tackling the many weaknesses in the medical industry. The team consists of 14 public prosecutors, plus accounting specialists and an IT forensic scientist. Since it was founded in September 2020, the ZKG has already initiated 568 new procedures and completed hundreds of old procedures. In the past twelve months, the special unit brought 20 charges and 30 penal orders to courts across Bavaria. Incidentally, the ZKG also receives tips – and “valuable” ones, not denunciations – via an anonymous reporting system.

On Wednesday, Findl took stock of the situation with Justice Minister Georg Eisenreich (CSU). Eisenreich took the opportunity to declare war. This is not about petty crimes. Criminal activities harmed patients, who had to fear for their health, and society as a whole. The German healthcare system now costs more than 460 billion euros a year. Most of the money comes from the state and health insurance companies. And where there is a lot of money to be made, criminals are not far away, warned Eisenreich and Findl. The ZKG boss and his people have recently mainly investigated the suspicion of invented or incorrectly billed corona tests. Every third ZKG procedure concerns corona tests, followed by almost as many suspected cases among doctors. Physiotherapists and nursing services each account for ten percent of the investigations.

Pharmacies also appear in the ZKG files. Findl reports on a case that will be heard at the Augsburg Regional Court in December. A pharmacist billed fake prescriptions in her name. Half a million euros in damage is said to have occurred in two years. Such bills went through easily, says Findl. “A lot has to happen before it is noticed”. Here it was a drug against psoriasis that a dentist found necessary. If you act “clever”, it doesn’t even come to light in the existing billing system. Another example concerns a suspected criminal nursing service that is said to have caused damage of almost four million euros. In such cases, the judiciary siphon off assets and confiscate cars, for example. “No Lamborghinis, but also no Fiats,” says Findl. It’s about returning the money to the cash registers or other injured parties.

Is it made too easy for scammers? Does the judiciary have to fix what is going wrong with the control of resources in the health system? You have to “remain fair,” says Eisenreich. The cooperation with the cash registers works well. It is important, however, that when the corona pandemic subsides, the health insurers check more closely on site whether the billed services are actually being provided. The “dark field” overall is large, “we don’t know the true extent,” complains the minister. At the request of Bavaria, the conference of justice ministers spoke out in favor of a nationwide dark field study. Findl refers to one such study from Great Britain across several countries. Accordingly, almost seven percent of the health budget would flow into dark channels. According to Findl, this is not necessarily transferrable to Germany. But you can see how easy it is “if you are of bad will”. If you take the British study as a benchmark, the damage in Germany would amount to more than 30 billion euros a year. That is almost half the Bavarian national budget.

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