Billing fraud committed by contract physicians or outpatient nursing services has been the focus of investigations and media discussion in the healthcare sector for years. The Fraunhofer Institute for Industrial Mathematics ITWM supports the efficient clarification with new methods.
Accounting fraud and corruption in the health care system are causing great damage to social insurance schemes throughout Germany. This results in enormous costs of an estimated 14 billion euros [1] per year for the solidarity community and the number of cases is rising sharply. In order to uncover such fraud networks, investigating authorities and health insurance companies spend a lot of time and effort evaluating large amounts of data containing many individual elements such as e-mails, account transactions or billing data.
The statutory health and nursing care insurance funds, their associations and the GKV-Spitzenverband have set up their own »bodies for combating misconduct in the health care system« in accordance with §§ 197a SGB V, 47a SGB XI. These investigation and examination offices follow up all indications that suggest irregularities in connection with the tasks of the statutory health and nursing care insurance. The fact that the complex service relationships in statutory health and long-term care insurance require extensive specialist knowledge is demonstrated by the newly established »Central Office for Combating Fraud and Corruption in the Health Care System in Bavaria« (ZKG), which was presented on September 10, 2020. The Fraunhofer ITWM helps to make such investigations more efficient with its many years of expertise in the areas of accounting auditing and damage extrapolation.
An effective fight against accounting fraud in outpatient care is particularly costly. Due to the special situation, it is very difficult to prove a complaint for individual services. Many »small« services play a role here, or even the indication of possibly demented patients is used for fraud. There is usually a lack of time and trained personnel for the verification. Experts of Fraunhofer ITWM support those responsible – such as law enforcement agencies – not only with experience knowledge. Fraunhofer ITWM has also developed efficient methods that enable faster billing checks.
Especially the damage extrapolation is to be mentioned here, which means a considerable relief for the investigators. »Our calculations give the investigating authorities the possibility to reliably pursue cases which cannot be completely determined due to the amount of small individual damages. We thus relieve the investigating authorities considerably«, explains Dr. Elisabeth Leoff of Fraunhofer ITWM. »In some cases, investigators only have to work one month on a review that previously took six months«.
Scientists of Fraunhofer ITWM offer workshops and trainings especially designed for damage extrapolation, which convey the damage extrapolation by means of the statistical environment »R«. By means of target group oriented advanced training events, for example in the context of the exchange of experiences at the GKV-Spitzenverband, the responsible employees of the statutory health and nursing insurance companies and representatives of the law enforcement agencies are sensitized. They learn how to use statistics efficiently, time-saving and error-resistant for data evaluation and damage extrapolation in the case of accounting fraud in the healthcare sector.
The methods of Fraunhofer ITWM are universally applicable. Thus, the algorithms can be applied not only for billing fraud of contract physicians or outpatient care services, but also for other investigations. In concrete cases, the statistical methodology is adapted to the individual cases in close cooperation with the investigating authorities and health insurance companies.
[1] Source: Press release of the Bavarian State Ministry of the Interior and for Integration, 27.03.2018 in Nuremberg
Fraunhofer Institute for Industrial Mathematics ITWM