Examples of fraud committed by different healthcare players
Overview
EHFCN calls on everyone to collaborate on eliminating fraud and corruption within healthcare.
Although we all know that the majority of people who work in healthcare and those who use healthcare services are honest, there is a minority who will seek to defraud healthcare resources. But we can all contribute to stop it if we are aware of the types of fraud that are committed and if we take a few simple steps.
Whether you are an employee in the healthcare sector, a contractor, a supplier of healthcare goods and services, a decision-maker or a member of the public, your contribution is vitally important. Join our fight against healthcare fraud and corruption. Also you can put a stop on healthcare fraud and corruption.
Recognise it: Below are a few examples that happened (quite) recently within the EU, which highlight the kind of problems that can be encountered.
Stop it: Despite the different healthcare systems and reimbursement methods, some advice is available. Although some may not be applicable in your country, some are worth taking into account wherever you are.
Healthcare providers
Fraud involving healthcare providers often includes
- alteration of prescriptions,
- claiming for work not undertaken and treatments not provided,
- creation of ‘ghost patients',
- fraudulent claims for out-of-hours visits,
- billing more by separating various aspects of one treatment in order to give the appearance of numerous procedures
- lies about qualifications in order to receive higher fees or salaries.
Claiming for non-provided treatments
A doctor in Germany earned extra money by claiming reimbursement for treatments which he had not provided. He allegedly gave pregnancy advice in high numbers, even to older women (above 80 years) and to small children (about 4 years). Additionally he allegedly managed to call 80 home visits in a few days. The investigation began when a sickness fund claimed a refund of the quarterly fee of one of the ‘patients' who assured he had never been to the doctor.
A GP in Ireland claimed fees for carrying out additional evening surgery sessions (after 6.30 pm) and evidenced this with records of patients who had actually been seen in normal surgery hours. £17500 repaid and investigation still ongoing regarding criminal charges.
In Spain, a nursing home invoiced double the staying of patients and medicins, for an amount of € 40.012,69. Another fraud case with a nursing home included false invoices, for an amount of € 810.403,55.
Performing unnecessary treatments & services
A chief surgeon at an Italian clinic in Milan performed unnecessary surgery on almost 90 patients. He engaged in complex operations which were not necessary but which were reimbursed by the Italian healthcare system. In some cases, the surgeon caused unnecessary suffering of patients in terminal stage. In other cases he caused patients' permanent physical injuries. He was sentenced to 15 ½ years imprisonment and tens of thousands of euros fines and damages.
Falsifying hundreds of prescriptions
A pharmacist in Spain would have falsified 200 medicine prescriptions. He followed two procedures whereby he either changed the name of the medicine into a more expensive one or he recorded the dispensation of two packs of medicine although only one was given. By doing so he increased the amount invoiced to the Catalan Health Service (CatSalut) for his own profit.
False statements
A GP in Oslo, Norway, District Court in december 2007 sentenced to two year and four months inprisonment for making false statements to NAV as a basis for disability pension for a lot of members of NAV. In the same case a false psychologist was sentenced to two years inprisonment. On the basis of this verdict, NAV, during the period 2008-2010, has evalueted disability pensions-cases, based on statements from these helath providers. Payment to more than 100 beneficiaries of disability pension has been stopped, based on this verdict.
In Spain, a pharmacy invoiced prescriptions with medicines not delivered to the patients in collusion with doctors. The amount concerned was around € 807.463,49. Another fraud case in Spain includes a private hospital forging information with the aim to obtain official prescriptions (financed by the public system) for an amount of € 5.238,78.
In Poland, cases with fraud involving healthcare providers included: issuing prescriptions for orthopaedic devices and reimbursed drugs to patients by medical doctors during the period when they were prohibited from performing their profession by a court order. And second, the extortion of public funds by service providers by way of misleading the National Health Fund in the scope of testifying in the medical documentation.
Patients
Patient fraud usually includes
- wrongful claiming of exemption from fees,
- alteration of prescriptions,
- using aliases to obtain controlled drugs.
Claiming exemption of fees
In Italy, over 600 people had been able to obtain the exemption of payment for healthcare received through false self-certifications. They pretended to be poor in order not to pay for the medical services and diagnostics they had used but they were not entitled to these exemptions. Among those reported are entrepreneurs, salespeople, artists, professionals, civil servants and false unemployed, who all receive a revenue, in a few cases even as high as a yearly income of over €100,000 and the ownership of luxury cars. One case even included a person who boasted a total household income of more than €300,000. The loss of income is estimated at over €1 million. All the suspects were referred to the local judicial authorities.
Wrongful claims
In France, the Brigade for fighting crime (BRDA) discovered that a fifty-year old man was affiliated with a dozen sickness or pension funds, to whom he provided the same records of care simultaneously. Thus, he was reimbursed up to twelve times his healthcare costs. Because his health expenditure was real, no fraud had been detected by the national health insurance. It is estimated that the suspect may have embezzled up to €450,000 in recent years.
In Ireland, a perpetrator rang a pharmacy pretending to be a member of staff from a GP practice and requested that drugs be dispensed to a named individual (fictitious of course) in advance of receipt of the prescription form which would be sent on. Another fraud case in Ireland include a family of a qualifying patient who received payments under the Direct Payments scheme for the care of the patient. The scheme has strict boundaries on how these monies should be spent and all spends must be evidenced. There was no evidence that any of the £18000 paid was spent on the direct care of the patient.
Patient fraud cases in Poland from the past include:
Presenting a falsified medical report containing an untruthful health condition description and doctor's recommendations to a general practitioner in order to extort prescriptions for reimbursed drugs, and performing changes in the specialist medical consultation document in order to extort prescriptions for psychotropic drugs.
Staff
Staff at hospitals or at healthcare companies can be tempted into:
- submitting false claims – for example, timesheet and payroll fraud,
- claiming for non-existent employees and for IT equipment never purchased.
In Scotland, some NHS staff have been prosecuted successfully for working in another job while pretending to be sick and receiving sick pay. Other examples in Schotland include Health Boards and other public bodies being subject to fraud attacks on their payment systems. In some cases, staff changed legitimate supplier bank details to those of bank accounts controlled by fraudsters who then submitted false invoices in the name of the genuine suppliers.
Healthworker defrauded GBP 1,500 'to support her family'
A health worker defrauded NHS Lothian by falsely filling out her time sheets. She did this because her partner at that time was unable to work due to a serious road accident. She claimed to have worked an extra 177 hours whilst working as a part time administration assistant. She was sentenced to 200 hours community service and commanded that she pay back the outstanding cash, which was a much lower sentence than originally anticipated.
Employee transfers healthcare company money to private accounts
A former employee of the Italian healthcare company ULSS 9, was accused together with other accomplices to have implemented a system through internal computers to steal resources from the company and transfer them to private accounts. The woman, according to the prosecution, had stolen through this system almost €4 million from public funds over a period of several years. She was sentenced to 11 years in prison and to the immediate return of the €4 million to the Veneto region.
Anaesthetic assistant steals vast amounts of medical supplies
An anaesthetic assistant was jailed for 20 months in 2010 for stealing vast amounts of medical supplies, including specialist surgical implants and skull drill bits, worth more than £23,000 (€ 26,000) which he then tried to sell on eBay. The man was sentenced during an appearance at Glasgow Sheriff Court. He stole the equipment while working at Glasgow's Royal Hospital for Sick Children, and the city's Southern General and Royal Infirmary hospitals, between Oct 2006 and Nov 2008.
Woman claimed sickness benefit while working
In 2010, a cleaner at Glasgow Royal Infirmary was sentenced to 150 hours community service, after she admitted defrauding NHS Scotland of over £2,300 (€ 2646). The woman was sentenced at Glasgow Sheriff Court. She claimed sickness benefit while working as a cleaner at Strathclyde University, between 23 June and 18 October 2009.
Contractors and suppliers
Fraud by contractors and suppliers often includes
- the submission of bogus invoices
- fraudulent claims by appliance contractors.
In the UK, a hospital engineer claimed he had requisitioned heating and engineering parts from a local engineering company, which were paid for by the trust. However, rather than the trust receiving the requisitioned parts, the company supplied the engineer with IT and electrical equipment for his own use.
In Italy, medical devices of seven companies who customize orthopedic equipment were seized as a precaution measure. The reasons included the lack of a business organization (equipment, premises and personnel) suitable for the construction of medical devices according to the standards of quality foreseen; the entry into service of medical devices that are not appropriate to the needs of patients and that even endanger public health; the lack of respect of the community, national and regional norms in the sector. The seven company executives were charged with fraud in the execution of public procurement and false instrument. The damage to the Regional Health Service for the period 2004 to 2007 is estimated at around €3 million.
In Ireland, a domiciliary health care provider has double- and triple-charged for a number of staff providing domiciliary health care services at a number of different locations at the same time.