Caregivers and physiotherapists who are not, billed for services that were never provided: As a result of these and other fraudulent crimes, the KKH Kaufmännische Krankenkasse suffered the largest loss to date of 4.7 million euros last year.
Outpatient care services are primarily responsible for the sad record. They swindled the largest chunk of almost 3.4 million euros at the expense of the KKH's health and nursing care insurance - namely around 70 percent of the total amount. The fact that this immense damage was discovered at all is primarily due to the success of the public prosecutor's investigation against several nursing services in the Augsburg area.
“It is always only a few black sheep who act criminally. But these enrich themselves with money that is reserved for the insured for the prevention and treatment of illnesses,” emphasizes KKH chief investigator Dina Michels. “Such fraudsters undermine trust in the entire healthcare system with their machinations and also bring the honest service providers in their respective professions into disrepute.”
Hundreds of new suspected cases, but still a high number of unreported cases
The tricky thing is that such crimes often don't even come to light. The number of unreported cases in the health sector is high and the loopholes for criminals are numerous. The KKH billing manipulation testing group received at least 352 new reports of fraud nationwide in 2021. At the top of the scale are nursing services with 147 suspects, followed by physiotherapists and physiotherapists (50 suspects) and doctors (35 suspects).
Overall, almost half of all references last year were in the area of nursing (46 percent). The spectrum ranges from nursing home and nursing service operators who charge too much for unqualified staff to insured persons who manipulate their level of care. Dina Michels is not surprised: Nursing is particularly vulnerable to crimes. The KKH has been registering the most cases in this area for years.
“On the one hand, the annual billing audits by the medical service have an impact here. On the other hand, there seem to be more and more people with a high level of criminal energy in this service area,” says the KKH lawyer.
From fake prescriptions to new areas of Corona fraud
But fraud occurs not only in care, but also in many other areas of the healthcare system - from pharmacies and hospitals to medical supply stores and dental practices. Dina Michels:
“Behind every case of billing fraud is an attempt to illegally maximize one’s own profits – always at the expense of the insured.”
Maximum rates are charged for unqualified staff, professional certificates and prescriptions are falsified, and treatments and medical trips are billed that are fictitious. In one of the most spectacular cases of the past, a pharmacist adulterated cancer drugs on a large scale. In doing so, he not only enriched himself by several million euros (1.5 million euros at the expense of the KKH alone), but above all endangered human lives.
The pandemic has also opened up further areas of fraud. Dina Michels lists as examples manipulated billing for corona rapid tests in various Berlin test centers, corona emergency aid amounting to millions in Hamburg that was illegally collected by the state, and fake vaccination cards that a man in Saxony is said to have resold to third parties.
“In these cases, the health insurance companies are not directly affected. But of course these offenses must also be uncovered and prosecuted as quickly as possible.”
A lack of specialist knowledge is a free pass for fraudsters
In order to be able to get to the bottom of such crimes, health insurance companies rely primarily on information from, for example, the Medical Service (MD), other health insurance companies, the media and the police. The KKH received the most tips last year from North Rhine-Westphalia (113). They are followed at a clear distance by Bavaria (33) and Baden-Württemberg (32).
“But these clues alone are not enough to arrest the fraudsters,” emphasizes Michels. A close-knit network of professional investigators is a prerequisite for a successful fight against criminal activity in the healthcare system. “It must no longer happen that justified procedures are stopped due to a lack of specialist knowledge. For the perpetrators, it's like a free pass.” In most federal states, specialized public prosecutors or specially trained criminal police inspectors are now intensively investigating property crimes and corruption in the health sector across the country. “This should be the case in all federal states as quickly as possible,” demands Dina Michels.
The TOP THREE according to the amount of damage in 2021 (rounded):
- Outpatient care (3.4 million euros)
- Medical service (375,000 euros)
- Travel costs (309,000 euros)
The TOP THREE by number of suspects from cases/tips in 2021:
- Nursing services (147)
- Physiotherapists/physiotherapists (50)
- Doctors (35)
The TOP THREE by number of initial suspicions in 2021:
- Billing for services not provided, so-called air services and prescriptions (123)
- Use of unqualified personnel (106)
- Billing without approval/approval/permission (32)
PODCAST
KKH conference “Fraud in the healthcare system”
The 9th specialist conference “Fraud in the Healthcare System” took place at the KKH on May 4th and 5th, 2022, under the patronage of Prof. Dr. Edgar Franke, Parliamentary State Secretary in the Federal Ministry of Health. The event, which was held hybrid this time, is still considered an insider tip with an exclusive character. The speakers include outstanding personalities from the judiciary, investigative authorities and the legal profession. The experts come from all institutions nationwide that are involved in the broadest sense - including scientifically - with combating fraud and corruption in the healthcare system. They discuss new case law, strategies for successful investigations and the effects of new laws on site and online.
A renowned expert in criminal corruption cases is senior public prosecutor André Schmidt from the Braunschweig public prosecutor's office: “Fraud in the healthcare system is not a trivial offense. Ultimately, we all pay, because the illegally withdrawn funds must be financed by the solidarity community.” And according to estimates from the Federal Statistical Office, spending in the health sector continues to rise - to a total of 466 billion euros in 2021 alone.
“This sum frees up a lot of energy for individual service providers to illegally collect money. That’s why it’s important that everyone responsible pulls together to combat crimes in the healthcare system,” appeals Schmidt. “In addition, the protection of whistleblowers is of particular importance so that the honest ones do not end up being the stupid ones.”
Further information about the conference can be found at kkh.de/abrechnungsbetrug . On this website, the KKH also receives tips about misconduct in the healthcare system, both by name and anonymously, via an electronic whistleblower system. Alternatively, this is also possible by email to fraudsverdacht@kkh.de .
Source: KKH
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