Fraud and Corruption in the Health Insurance Industry

Transcription

1 Fraud and Corruption in the Health Insurance Industry Georgia Skorczyk Area Manager Human Resources and Legal Department of the Techniker Krankenkasse SAS Forum /23. May 2007 in Stockholm

2 Introducing the TK Basic Information as of Founded: Members / Insured Parties: CHI Market Share: Budget 2006: Employees: Volunteer TK-Advisors: National Premium Rate: TK risk adjustment payments (RSA): 27 October 1884 in Leipzig as the Registered Assistance Fund for German Architects, Engineers, and Technicians" 4 Million / 6.1 Million 7.9% Approx billion EUR in over 200 locations, including 509 trainees in businesses and colleges Contact people for social welfare matters 13.5 % (since ) Additional premium rates for employees: 0.9% (since ) 3.7 billion Euro (in 2005) 38.0 billion Euro (since 1994) 2

3 The reasons why all health systems are vulnerable to corruption Complexity of all health systems - large numbers of parties involved - complex relationships between medical suppliers, health care providers, policy makers & patients - high legal complexity Uncertainty in health markets - not knowing when and what illness will occur - not knowing who will fall ill and it what numbers - not knowing the effective treatment and its costs Imbalance of information - health professionals having information than patients Health Expenditures globally about 3 trillion a year And last but not least: health is not a normal commodity: It is extremely valuable. 3

4 Fraud and corruption in the health sector: an overview (I) Professional fraud and corruption - doctors claiming for patients they have not treated - doctors claiming for more treatments than they have actually done - doctors claiming for treatments which are not part of the benefit system Service Providers/Suppliers fraud and corruption - suppliers deliberately supplying second-hand goods, declaring them new - suppliers not passing on the discounts they receive to the health insurers - suppliers wrongly confirming entitlements to benefits - pharmacists billing wrong prices - pharmacists adding medicaments to the prescription or increase the prescribed quantity 4

5 Fraud and corruption in the health sector: an overview (II) Patient fraud and corruption - patients declaring they have lower salary in order to pay less for healthcare - patients creating multiple identities in order to receive numerous prescriptions to receive beauty articles instead of medication - patients giving away their health insurance card to people who are not entitled to healthcare by this health insurance Staff fraud and corruption - supporting patients, professionals and suppliers Criminal networks - stealing of prescriptions and health insurance cards Very special: Counterfeiting - endangering lives and generating costs - Estimated value: about 17 billion a year 5

6 CHI Regulatory framework Overview of Service Providers Contracted Dentists approx. 144 Billion Euro for Health Care Contracted Doctors Pharmacies Other Service Providers A choice of: approx orthopaedic technologist approx Optometrists approx Midwives approx Physiotherapists approx Emergency Service Workers Emergency Hospitals Source: - Bundesministerium für Gesundheit und Soziales (Statistik KV 45), Telemedizinführer Deutschland,

7 CHI Regulatory framework Service and Accounting Structure I Health Insurer Insurance Premiums Claimed expenses Invoicing Payment Service Provider Treatment Member/ Insured Party 7

8 CHI Regulatory framework Lack of Transparency and Potential for Abuse Core Problem: Lack of Transparency Lack of transparency in the German Health Care system a core problem This is responsible for: Above average costs Not reaching full performance potential, the German health care system only delivering average performance (Bertelsmannstudie 2001) Additionally hundreds of individual cases of fraudulent or corrupt practices have arisen unfortunately, the honest party (Doctor, Pharmacist, Physiotherapist) usually suffers. A thorough examination of the inefficiencies caused by a lack of transparency, poor leadership and fraud is not taking place. 8

9 Combating Insurance Abuse in the TK Investigation Group for Fraudulent Invoicing Directors Human Resources and Legal Department 197a- Position Investigative Group Clerical Staff General Administration Clerical Staff For fraud cases: - Investigations - Meetings of the Health Insurance Employees Association Legal Case Management Including filing charges on behalf of TK Data Analyst Fraud Detection Central Coordination 9

10 Combating Insurance Abuse in the TK Investigation Group for Fraudulent Invoicing Tasks of the Investigation Group Monitoring of internal and external indications of insurance abuse Processing and management of abuse cases Filing complaints/ reporting offences Establishing abuse identification grid through pattern analysis Cooperation with Federal prosecutors, criminal police and other health insurance companies. Representation of TK interests at the Federal level in all insurance abuse matters. 10

11 Combating Insurance Abuse in the TK Investigation Group for Fraudulent Invoicing Reasons for Investigation Monitoring System Abuse Identification Raster Advice from public prosecutors and police Investigation by investigative group Cooperation with other members of the Health Insurance Association and advice from other insurers. Advice from insured parties, public authorities, social welfare agencies, service providers and third parties. 11

12 Combating Insurance Abuse in the TK Investigation Group for Fraudulent Invoicing Notification Recording Inquiry Legal Processing Notification via advice from internal or external sources Data analysis according to investigative group identification raster Sorting according to regional jurisdiction. Prioritisation Entry into data bank Inspection of Case Request for accounts documentation Assessment of facts Breach of contract or fraud? Determine future action Filing of complaint, monitoring Damages ruling in or out of court Confirmation of initial position Damages assessment 12

13 Combatting Insurance Abuse in the TK TK Abuse Prevention Processes Verax List TK registers blocked cards in the software used by independently operating physicians and dentists (80% of practitioners), blocking up to three million cards and saving 50 million Euro. Abuse of stolen, found or illegally sold cards Incorrect premium exemptions 13

14 Combating Insurance Abuse in the TK Abuse Identification Raster TK Monitoring the Abuse Identification Raster Using data to stop known abuse and fraud practices Manipulated invoices, charging for higher value services (eg Optometrists) Patient transportation fraud Multiple invoicing Supply of unnecessary services (physiotherapy, midwifery and other service providers) Embezzlement of transferable discounts (dental laboratory, dentists) 14

15 Combating Insurance Abuse in the TK Abuse Identification Raster The TK Data Warehouse The uniform and consistent database for all data analysis TK- Insured Parties (anonymous) SAS Invoicing Doctors SAS Invoicing Hospitals SAS Invoicing Pharmacists SAS Invoicing Medication and Medical Aids SAS... SAS... SAS 15

16 Combating Insurance Abuse in the TK Abuse Identification Raster Using the TK Data Warehouse Doctors Health Insurance data TK Insurance Abuse Investigation Group Pharmacy Prescription Information TK Data Warehouse SAS Hospital Invoicing data other Service providers Invoicing- and Consultation data SAS- Enterprise Guide Case Data Bank Fraud Pattern Abuse Identification Raster Suspicious Invoices 16

17 Combating Insurance Abuse in the TK Abuse Identification Raster Abuse Identification Raster All invoices to be checked Non suspicious invoices Raster Analysis should identify all red invoices and a minimum of green invoices Suspicious invoices Individual checking 17

18 Combating Insurance Abuse in the TK Working Example Optical Aids The Case: Incidence: Optometrist charges for high value optical aids (multi-focal lenses) although single strength lenses or even sunglasses were delivered. Nation wide Damages: up to Status: Found through: Charges have been filed. Abuse Identification Raster analysis 18

19 Combating Insurance Abuse in the TK Working Example Dental Prosthesis from Abroad The Case: Dentists work with laboratories and order dental prostheses from abroad, but charge the highest German prices. Case Globudent: 423 cases against dentists. Further laboratories are being targeted. Incidence: Nation wide. Damages: in total 4.5 million Euro (Globudent) Future cases: not yet calculable Timeframe: 10/99 until 02/2003 Status: Globudent: Trial completed. Future cases: Charges have been filed. Trial underway. Found through: Media, Abuse Identification Grid analysis 19

20 Combating Insurance Abuse in the TK Working Example Stolen Health Insurance Cards The Case: Medications: Incidence: Damages: Status: Found through: Doctors and Pharmacists exploit false, stolen or found health insurance cards. Multiple prescriptions are taken to pharmacists and charged. Stomachic, pain relievers in inconspicuous amounts Hamburg Several hundred thousand Euro Charges have been filed. Routine checking (Statutory liability checking) 20

21 Combating Insurance Abuse in the TK Working Example Stolen blank original prescription forms in 2004: Dealing with stolen prescription forms from 25 Doctors. Included 1 doctor from Saxony and 1 doctor from BRB : Notification from pharmacist Charges filed by pharmacist/ Lodged in STA Braunschweig 3 doctors (including 1 from Dresden) 119 pharmacists : Notification from AOK Nationwide use of prescriptions : Notification from police 2 doctors and 32 pharmacists Trial started by TK Clear involvement of: Bayern Berlin and Berlin : Notification from police; Arrest of 2 suspects 1 doctors and 19 pharmacists Charges filed by TK : Notification from police 1 doctor and 1 pharmacist Charges filed by TK : Notification from TK 9 doctors (including 4 from Leipzig) ) and 31 pharmacists Charges filed by TK : Notification from TK 5 doctors and 26 pharmacists Charges filed by TK : Notification from TK; 1 Berlin doctor and 14 pharmacists, complaint filed by TK, Prescriptions from these doctors turned up in 9 other cases and were used in 8 further states (total 253 prescriptions from these doctors) : Notification from police 3 doctors and 28 pharmacists Charges filed by TK/ Trial commenced by STA Berlin : Notification from police 4 doctor and 34 pharmacists : Notification from police 2 doctors and 60 pharmacists : Notification from doctor 1 doctor and 1 pharmacist : Notification from police 3 doctors and 9 pharmacists from Saxony, One from Thuringia and 76 Berlin pharmacists : Notification from TK; 6 doctors and 42 pharmacists (9 Baden Wüttenburg, 1 Brandenburg, 13 Lower Saxony, 3 Saxony, 16 Berlin) : Notification from TK 1 doctor and 5 pharmacists; charges filed by TK : Notification from TK; 8 doctor and 29 pharmacists; charges filed by TK : Notification from TK; Bulletin to all dentists in Berlin; 6 pharmacists in Baden-Wüttenburg, 1 Brandenburg and 34 Berlin pharmacists 21

22 Future Prospects Creation of the electronic Health Insurance Card The electronic Key in the Patient s Hand: Memory Card Only a memory card, like a blackboard Can be read by any machine Data can be altered by anyone Processor Card Mini computer with own secure operating system Memory only accessible by authorised points (read, delete, change, conceal) Only for use by the authorised person Encrypted data Secured data The creation of the electronic Health Insurance Card (HIC) will replace all existing health insurance cards. 22

23 Future Prospects Creation of the electronic Health Insurance Card Security Features of the HIC Security Features of the HIC Passport Photo PIN Code Copyrighted 23

24 Our mission: We want to create an Anti-fraud and Anti-corruption culture among all participants of the health care system We want to deter by actively expose those who engage in fraud and corruption We want to use state of the art IT systems to detect fraud and corruption We want to use effective prevention systems so that when criminal activities are attempted they will fail We want to seek financial redress in order to get back the financial resources lost to criminal activities and to give them back to our clients We want to make the public aware of the great impact fraudulent activities have on the health sector 24