Electronic patient file: Using the app to combat billing fraud

Electronic patient file: Using the app to combat billing fraud

A visit to the doctor is made easy in Germany, apart from the waiting time in some places: scan your insurance card at registration, talk to the doctor, take the prescription with you, and you’re done. But which activities doctors bill for is usually left in the dark for patients. This could change if the electronic patient record (ePA) becomes mandatory for everyone with statutory health insurance from 2025.

And something else will happen: it will become much easier to detect billing fraud.

In order to keep track of which diagnoses doctors have made and which therapies they have prescribed, Many health insurance companies already offer a smartphone app. The patient file will be mandatory from 2025. It is intended to help avoid expensive and unnecessary double treatments and to facilitate research with anonymized patient data.

Until now, there was little control over what doctors billed – and therefore little chance of detecting questionable medical services or even fraud. Because of medical confidentiality, health insurance companies cannot easily look deeper into doctor’s files, even if they find billing suspicious.

And according to its own information, the National Association of Statutory Health Insurance Physicians (KBV) relies on information from patients, doctors or pharmacists; it only occasionally goes through suspicious bills itself. And according to the regional associations of statutory health insurance physicians, many patients came forward primarily because they felt that the doctor was not treating them as expected. So not with any indications of possible billing fraud. “Chance plays a big role in the discovery,” says one Study by the auditing firm PricewaterhouseCoopers from 2021.

The author’s electronic patient record showed abnormalities

The most recent report prepared by the KBV for 2020/21 shows almost 1,200 tips, of which almost 240 turned out to be justified, and 16 cases resulted in criminal proceedings. According to the report available to ZEIT ONLINE, this resulted in 14 million euros in damage – only a tiny fraction when you consider the large number of doctor’s visits and the 290 billion euros total expenditure the statutory health insurance funds. The health insurance companies not only assume that the number of unreported cases is high, but also that it has recently continued to rise the PwC study.

For years, patients in the practice have been able to have a so-called patient receipt written out, which documents the diagnosis and therapy and thus makes the doctor’s actions verifiable. But this is largely unknown and rarely used. “Only a few people do it because there is little interest in it,” says a spokesman for the Baden-Württemberg Association of Statutory Health Insurance Physicians.

The electronic patient record could now change that. This is exemplified by the case of the author of this text: he was ill with Corona in September 2022 and took sick leave over the phone. Six months later, in his patient file, he found in the health insurance company’s “billing data” document under the doctor’s “services” a “surcharge for family doctor care” documented, as well as a “surcharge for hygiene”, an “additional flat rate for the performance of the family doctor’s care mandate” and a ” Emergency data record – all positions that one would not immediately associate with a telephone sick note.

When the insured person asked the health insurance company, the insurance company forwarded it to the State Association of Statutory Health Insurance Physicians (KV). They came to the conclusion that “there were indications” that the billing was incorrect. She asked the insured person to release the doctor from his duty of confidentiality so that the KV could question him about the case. That’s what the association did. As a result, “the information was essentially confirmed,” the KV then confirmed to the insured, without going into detail, and thanked them because “damage caused to the solidarity community could be averted.”

Investigate more fraud cases

Such audits are not without risk for medical practices: sensitized by the individual case, the KVs often look for further abnormalities in the invoices. This can lead to further in-depth examinations and painful repayments.

The more insured people use the ePA apps, the more such tips and inquiries there could be: “We assume that the number of tips will increase due to easier access to this data and that more cases of fraud may be able to be investigated as a result of this increase “says a spokesman for Germany third largest health insurance company DAK on request. The Techniker Krankenkasse also sees it this way: “The fact that interested parties have the opportunity to use an ePA to see what has been billed for them definitely increases the chance of uncovering more cases of fraud,” says a spokeswoman for Germany’s largest statutory health insurance fund.

The ranks of the traffic light coalition are also optimistic about curbing criminal activity: “The sovereignty of the insured over their own data not only contributes to greater transparency and patient safety, but can also lead to billing fraud being detected more often,” says the health policy spokeswoman for the SPD parliamentary group, Heike Baehrens, ZEIT ONLINE.

However, pointing out possible fraud can also have consequences for insured persons. Especially if you have released the doctor from confidentiality. Because this also tells the doctor that you have contacted the health insurance company or KV. The relationship of trust between patient and doctor is then likely to be destroyed and a change of doctor will probably be unavoidable. At least that’s what happened to the author.

Source link