Medical Billing Record Manipulation in Germany: How Health Insurers Detect It
What is medical billing fraud (Abrechnungsbetrug)?
It is when healthcare providers (such as doctors, hospitals, or therapists) submit false or inflated invoices to a health insurance fund in order to obtain undue payments.
Common examples
Billing for treatments that were not provided
Exaggerating the number or duration of sessions
Using incorrect diagnosis codes (ICD) to justify expensive treatment
Listing non-covered services as if they were covered benefits
How do insurers detect this manipulation?
Germany’s statutory health insurers (GKV) use strict anti-fraud mechanisms, including:
Automated digital checks (Digitale Prüfverfahren)
Algorithms look for:
Unusual billing patterns
Abnormally high treatment volumes compared to peers
Illogical repetition of certain services
Internal medical review (Medical Service – Medizinischer Dienst, MD)
Suspicious claims may be referred to the MD for assessment.
Medical experts evaluate whether the service was necessary, plausible, and medically justified.
Plausibility checks (Plausibilitätsprüfung)
Comparing documented working hours with the number of billed patients/cases.
Example: A doctor cannot realistically examine 80 patients in 6 hours in a detailed, properly documented manner.
Reports from staff or patients (Whistleblowers)
Anti-fraud units may receive tips from:
former clinic employees
patients who notice billed services they did not receive
pharmacists who detect forged prescriptions or suspicious patterns
On-site inspections (Vor-Ort-Kontrollen)
In some cases, inspectors review records directly at the practice or facility.
Possible consequences for providers or insured persons
Individual doctor: fines, repayment claims, professional sanctions up to loss of license/approval
Medical center or hospital: criminal investigation, termination of contracts, repayment claims
Insured person: loss of eligibility for certain benefits and legal action if involvement is proven
Serious cases may be forwarded to the public prosecutor’s office (Staatsanwaltschaft).
Can patients review their records?
Yes. As an insured person, you can request a detailed overview of billed costs from your insurer.
If you find services you did not receive, you can:
file an objection (Widerspruch), or
contact Unabhängige Patientenberatung Deutschland (UPD) for support.
Summary
German health insurers are well equipped to detect billing fraud.
Any suspicion is taken seriously and investigated thoroughly.
Patients play an important role by checking bills and reporting irregularities.
ـ* The website’s writers and editors strive to provide accurate information through extensive research and multiple sources. However, errors may occur or some information may be unconfirmed. Please treat this content as an initial reference and always consult the relevant official authorities for verified information.
