In an interview with MedLabPortal , Dr. Wolfgang Matz, Chairman of the Board of Directors of KKH Kaufmännische Krankenkasse, talks about record losses due to billing fraud, KKH’s recipe for success, the role of whistleblowers and the need for cross-health insurance data analyses with AI. Matz also explains why tax financing of non-healthcare services would be fairer – and shows the potential of health insurance companies as active controllers of patient care.

MedLabPortal: Mr. Matz, KKH is considered a pioneer in the systematic fight against billing fraud and corruption in the healthcare system. It is the first health insurance company operating nationwide to set up its own work area (Billing Manipulation Review Group) that deals exclusively with this. Despite rising losses (record €5.4 million in 2024), there are measurable successes through preventive and repressive measures. What is your recipe for success?

Matz: To successfully combat misconduct, we are primarily dependent on whistleblowers. Employees of the medical service, the police, the tax offices and the media, as well as insured persons, contribute to preventing damage from the community of solidarity by providing information. Currently, however, only a fraction of the facts are identified. We look for irregularities such as double bookings in data sets and also randomly in performance records. However, this is only successful to a limited extent, as the fraud usually takes place across health insurance companies. A data analysis procedure that draws on the actual, full billing volume of all health insurance companies would be an effective tool to actively detect fraud.

MedLabPortal: The KKH organises the annual symposium “Fraud in the health care system”. There, case studies, legal issues and prevention strategies are discussed with experts, authorities and other health insurance companies. What is the response from the ranks of politics?

Matz: Our symposium is aimed at all stakeholders in the healthcare sector who come into contact with this topic – in particular other health insurance companies and law enforcement agencies, but also associations of statutory health insurance physicians, medical associations, pharmacists’ associations, judges, lawyers and service providers as well as their associations. This diverse network not only provides technical input, but also provides an important platform for discussions on demands and challenges for politics, legislators and society. Together, we called for a clear legal basis for cross-health insurance developments and applications of AI in the fight against misconduct. The legislator has listened to this call and actually an amendment to the law should be made within the framework of the Health Care Strengthening Act (GVSG ). However, due to the change of government at the beginning of 2025, the GVSG was greatly reduced and unfortunately passed without the amendment. Nevertheless, our demand is not off the table, the need is known and legal implementation is still planned. The National Association of Statutory Health Insurance Funds recently announced a dark field study on combating misconduct – also with AI. Other important demands, such as the establishment of nationwide specialised law enforcement authorities, are voiced by public prosecutors, police, health insurance companies and the judiciary, but in some cases they are not or only cautiously taken into account.

MedLabPortal: The political restraint surprises us. In Great Britain, Jim Gee celebrated sensational successes on behalf of the NHS about 20 years ago with the then newly established anti-fraud authority and has since recouped billions – but also because billing fraudsters lose everything there: Anyone who deceives the state has no place in the health care system. Why does a more consistent sanction fail in Germany?

Matz: Uncovered cases of fraud and corruption in the health care system are consistently prosecuted under social and criminal law. Offenders who act systematically are sometimes subject to severe penalties and must expect professional bans.

Unfortunately, however, the dark field is very large: Based on an international study from Great Britain, about 6.19 percent of annual health expenditure could be attributable to fraud. Transferred to the local conditions, an amount of about 20 billion euros could therefore have been used inappropriately. It is obvious that this could be relevant to the contribution rate.

MedLabPortal: This would reduce some of the statutory health insurance losses. Its cash register closed in 2024 with a loss of around 189 million euros. What was the reason?

Matz: The increasing deficits of the statutory health insurance funds are essentially politically caused. For years, statutory health insurance expenditure has been rising much faster than revenues, but politicians have not yet found any structural answers to this. On the contrary, several reforms in the last legislative period have even accelerated this process by depriving us of important control options. These have a particularly strong impact on expenditure on hospital treatment and medicines. To make matters worse, the health insurance companies were repeatedly obliged to reduce their reserves and that they had to take on additional tasks without sufficient counter-financing. Our insured structure also plays a major role for KKH: We care for an above-average number of chronically ill and multimorbid people. These insured persons naturally cause higher costs, but are not covered by the risk structure compensation to cover costs. At the same time, young, healthy insured persons who are covered up from a cost point of view are more likely to change insurers, which further exacerbates the imbalance. Despite these challenges, we have invested heavily in modernizing our IT over the past three years. This will strengthen our performance and service quality in the long term. In addition, we expect to keep our additional contribution stable this year.

MedLabPortal: The fact that the health insurance companies have entered into the political bashing against citizen benefit recipients surprised not only us. Anyone who loses their job at 55 after thirty years of work at VW or Bosch ends up with basic security after a maximum of 24 months. Do you see this as the real burden on the statutory health insurance system?

Matz: We expressly do not participate in this bashing. Our criticism is not directed against those receiving citizen’s money, but against the regulatory system. Of course, people in a social emergency must be entitled to medical care – this is a cornerstone of our welfare state! However, the financing of such tasks for society as a whole must not be one-sidedly through the contributions of those with statutory insurance. The GKV is mainly borne by people with low and medium incomes, as they are compulsorily insured. If non-pension benefits, such as the full assumption of contributions for recipients of citizen’s allowance, are financed from contribution funds, this places a disproportionate burden on precisely these groups. In this case, financing through tax revenues would be fairer because it includes all income groups – including civil servants and people with very high incomes. Tax financing distributes the burden more broadly and is more oriented towards economic performance.

MedLabPortal: Of course, we also have millions of people who, as refugees, did not have the chance to pay into our social systems, but are still entitled to adequate medical care. They are also among the clientele of basic income support – don’t you think the discussion about the 60 billion euros around the citizen’s allowance is inappropriate for humanitarian reasons alone?

Matz: The question touches on the same core: Medical care for refugees is a humanitarian obligation of our welfare state – and rightly so. However, if society wants this task politically, it must also be financed by society as a whole. Humanity and regulatory clarity are not mutually exclusive. On the contrary, fair financing strengthens the acceptance of our welfare state.

MedLabPortal: The chairman of the German Society for Clinical Chemistry and Laboratory Medicine, Jan Wolter, put it in a nutshell at the beginning of January: He called for a total reset of the health care system. What could or should a realignment look like from the point of view of the health insurance companies?

Matz: The financing of statutory health insurance and social long-term care insurance is under enormous pressure. According to a forecast by the IGES Institute, social security contributions will rise to over 43 percent by 2027. Without reforms, they could even climb to almost 50 percent by 2035. This is neither economically nor socially sustainable. We therefore need far-reaching structural reforms in all areas of care. The hospital reform must be implemented consistently and without exemptions for individual states. The goal must be to concentrate on quality, clear performance mandates and more efficient structures. The introduction of a primary care system is also urgently needed. A digital initial assessment, combined with a strong initial contact with a family doctor, improves care management, prevents duplicate examinations and relieves the burden on specialists and clinics. The health insurance companies have presented a viable concept for this.

The reform of emergency care and the rescue service is also long overdue. It has been announced again and again for years, but never implemented. Integrated emergency care would pool resources and reduce false incentives. Until structural reforms take effect, transitional measures are necessary, such as stronger tax financing of non-healthcare services, a dynamisation of the federal subsidy or a reform of drug pricing. Only a combination of short-term stabilisation and long-term structural reforms can secure the system in the long term.

MedLabPortal: Better control of patient flows is one of the central concerns of the current government. Are there any further ideas on the part of your health insurance company here?

Matz: In our opinion, it is precisely this point of control within the supply process that offers outstanding further – as yet largely untapped – potential. We health insurance companies have a unique data situation on our insureds. This enables us to identify possible risk potentials among our policyholders at an early stage. Addressing and providing targeted support to insured persons that is tailored to the respective risk with easy-to-understand information and advice on specific care offers helps patients to deal with their specific challenges and leads to an improved overall health situation in the long term. Here, § 25 b SGB V , which was newly introduced in the last legislative period, offers an important new control lever, which, however, remained limited to certain indications. The paragraph should urgently be further developed in this legislative period.

In addition, as part of an innovation fund project, the KKH has been able to prove that we as a health insurance company can also take on a helpful steering function in specific illness situations that meaningfully complement our medical work. With our care approach, we were able to improve the situation of patients with peripheral arterial occlusive disease (PAD), also known as intermittent claudication in common parlance, and in the end even avoid or delay hospital admissions. The entire project is not set up as a competitor to medical care, but as support, whereby we as a health insurance company support those affected in everyday life with their illness, especially with telephone health coaching and targeted information. A survey of the participating patient group showed exceptionally high approval ratings for this approach.

We know that health insurance companies can make a concrete contribution to improving care outcomes. I would like to see politicians give us much more room for manoeuvre at this point and, in the best case, even make us obligated to act in the sense of supportive care management. I am firmly convinced that health insurance companies should prove their quality through their range of care and service. The currently dominant price competition must be accompanied by competition for care offers. This requires further incentives, which can only be set politically.

MedLabPortal: You talk about broader competition between health insurance companies, others are thinking about whether a health insurance company within the statutory health insurance system would not be sufficient….

Matz: The German health insurance landscape has grown historically and is internationally unique in this form. Competition between health insurance companies ensures innovation, quality, efficiency and freedom of choice. A single health insurance fund would destroy this dynamic. It is very unlikely that a large central organization will work more efficiently – on the contrary: large monopolies tend to be bureaucratic, inert and lack of customer proximity. Moreover, the argument of high administrative costs does not stand up to factual scrutiny. The share of administrative expenditure in the total expenditure of statutory health insurance (GKV) has been declining for years and is well below the level of private health insurance. In Austria, the reform of the so-called “patient billion” was initiated in 2018 with reference to high administrative costs. The number of social security institutions was reduced from 21 to five by means of a forced merger. However, the desired increase in efficiency has not been successful: the reform has caused additional costs of €215 million in total. I am sure that the health insurance companies themselves are in a position to continuously reduce their administrative costs through digitalisation, increased efficiency and competition. For example, the share of administrative costs in total expenditure in statutory health insurance fell from 5.25 percent in 2012 to 4.12 percent in 2023. All this does not mean that the long-standing concentration process should not continue. A good 25 years ago, there were still around 420 health insurance companies, today there are only 93. Around 90 percent of insured persons are already organized with the 30 largest health insurance companies – so the process has already made significant progress. Whether we need a good 90 health insurance companies can be questioned; we need competition in any case. I am convinced that customers benefit from this. Competition ensures efficiency, innovation and that the health insurance companies are oriented towards the needs of the insured.

MedLabPortal: While we’re on the subject of potential changes: As the board member of a fund with 1.5 million insured persons, what would you like to see from Federal Minister of Health Nina Warken for 2026?

Matz: Above all, we would like to see decisive political action along a clear agenda. Concrete reform proposals have been on the table for years, but instead of making decisions quickly, new working groups and commissions are being set up, whose mandate would have to be clearly specified. The commissions can promote the implementation of a political agenda, but they cannot develop the political will. In addition, the Minister of Health has not succeeded within the coalition in securing the financing of the necessary reforms and the short-term stabilisation of statutory health insurance and long-term care insurance. We need the willingness of politically responsible actors to make even unpopular decisions, to communicate them to the population and to implement them consistently. The challenges are certainly great; Nevertheless, I think it can be solved if politicians are really willing to act.

MedLabPortal: The benefits of the health insurance companies within the statutory health insurance are prescribed and the same for most treatments. In times of tight budgets, why should someone choose a health insurance company that is significantly higher than its competitors in terms of additional contributions?

Matz: Because the price is only part of the truth. The health care system is becoming more and more complex, especially for people with chronic and multimorbid illnesses. The various health insurance companies differ significantly in their care programmes for the chronically ill, their digital services and personal care, the quality of their prevention services and health courses, their family benefits (e.g. midwifery programmes, child prevention, care advice), their optional tariffs and bonus programmes, as well as their service quality and accessibility. This development will continue with the possibilities of increased data use for individual support for insured persons in everyday care. These differences will further drive the concentration process among health insurance companies. Insured persons benefit from health insurance companies that actively support, manage and accompany them, and not only from those that offer the lowest additional contribution.

MedLabPortal: Mr. Matz, thank you very much for your time!

The questions were asked by Marita Vollborn and Vlad Georgescu

Editor: X-Press Journalistenbüro GbR

Gender Notice. The personal designations used in this text always refer equally to female, male and diverse persons. Double/triple naming and gendered designations are used for better readability. ected.