Billing fraud in the healthcare sector continues to increase. This is the result of the 2024/2025 activity report of AOK NordWest, which was presented to the Board of Directors. The fund’s seven-member investigation team is currently processing 1,670 cases in Westphalia-Lippe and Schleswig-Holstein – an increase of 22.6 percent compared to the 2022/2023 reporting period (1,362 cases). In total, almost 7.5 million euros in unlawfully billed services have been recovered in the past two years, almost twice as much as in the two previous years (around 4 million euros).

The increase in the number of cases is attributed to a higher level of awareness among the population and associated reports by third parties. In addition, AOK NordWest now carries out consistent audits based on many years of experience, even in the case of initially inconspicuous billing. The most common allegations concern services not provided, falsified prescriptions, invented treatments, lack of qualifications and manipulated billing.

The investigation team works closely with other health insurance companies, criminal police, main customs offices and public prosecutors’ offices. If suspicions are confirmed, the public prosecutor’s office is called in, damages are demanded and further cooperation with the service providers concerned is examined. Most service providers bill correctly, but a few cases can shake trust in entire professional groups.

The Board of Directors of AOK NordWest calls for a determined fight against fraud and corruption in the healthcare sector. The expansion of specialized police units and the establishment of special public prosecutor’s offices for white-collar crime in the health care system in Westphalia-Lippe are demanded. So far, a bundled responsibility has not been sufficiently prioritized.

Particularly frequently affected are falsified invoices in nursing, in which services were billed that were never provided or the qualifications of the staff were incorrectly stated. In individual cases, services were billed simultaneously at different locations (“beaming”). In an occupational therapy and physiotherapy practice, treatments were provided by an unqualified person and billed in the name of a former therapist – damage around 566,000 euros. One pharmacy attracted attention by dispensing high-priced drugs that did not fit the clinical picture; an investigation is underway. A dentist in Schleswig-Holstein billed in several cases for services not provided. In addition, there were counterfeit prescriptions nationwide for so-called weight loss injections, which are only reimbursable for diabetes – AOK NordWest alone suffered a loss of around 345,000 euros.

The amounts recovered are mainly divided between medicines and dressings (3.63 million euros), home nursing (2.8 million euros), insurance-related benefits (367,000 euros) and remedies (340,000 euros). AOK NordWest is calling for data protection regulations that enable the use of artificial intelligence for fraud prevention and allow the direct exchange of data between social security institutions.

AOK NordWest accepts information about misconduct on the hotline 0800 2655-505780, by e-mail to bekaempfung_von_fehlverhalten@nw.aok.de or online at aok.de/nw.

Editor: X-Press Journalistenbüro GbR

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