Health insurance fraud

History

2024: The head of the Tomsk clinic "Sante" received a year in prison for embezzlement of compulsory medical insurance funds

On September 11, 2024, one of the former top managers of the Sante clinic in Tomsk, Pavel Khramov, was sentenced to one year and three months in prison for fraud related to the theft of funds from the compulsory health insurance fund (compulsory medical insurance). The trial took place in the Kirovsky District Court of Tomsk, which found him guilty of committing a crime on an especially large scale. According to the prosecutor's office, Khramov and his accomplices organized a scheme that made it possible to illegally steal more than ₽25,5 million. Read more here

2023

Hospital workers in the Yamalo-Nenets Autonomous Okrug were accused of embezzling 314 million rubles from the compulsory medical insurance fund

The prosecutor's office of the Yamalo-Nenets Autonomous Okrug approved the indictment in a criminal case against four former employees of the Labytnangskaya City Hospital GBUZ. They are charged under Part 4 of Art. 159 of the Criminal Code of the Russian Federation (fraud), part 2 of Art. 187 of the Criminal Code of the Russian Federation (illegal circulation of funds for payments). The press service of the Prosecutor General's Office announced this on November 7, 2023. Read more here.

VHI fraud schemes identified in 5% of accounts from Russian polyclinics

Fraud schemes VHI with identified in 5% of accounts from. Russian polyclinics This was announced on October 19, 2023 by the company. Mains Lab (Mains Lab)

On average, about 5% of bills issued the Russian by polyclinics under voluntary (VHI) programs medical insurance contain services that either patients do not need or are not physically provided to them.

Medical and preventive institutions (LPU) have found ways to systematically overestimate bills for their services under VHI programs. The Mains Lab team (Mainsgroup Group) analyzed big data on more than 4 million cases of insurance companies paying for LPU services and identified fraud patterns in them. According to the study, about 5% of the bills from the clinics contain referrals for tests, treatment courses, repeated appointments and other medical services, which are either in principle not needed by patients for health reasons, or have not been provided at all and exist only "on paper."

The analysis also revealed the most popular fraud schemes. Almost 35% of detected cases of fraud are in the scheme of expanding the diagnosis. Its essence is that usually insurance quickly prohibit any services that are not due to diagnosis. To bypass this obstacle, the patient is given the most "streamlined" diagnosis like bronchitis instead of a runny nose. This allows you to expand the range of directions to be discharged.

Another 17% of cases occur in the addition of services. With such a scheme of fraud, in the account of the patient who received the necessary medical services, in addition to the services actually provided, which the clinic "added." As a rule, they are selected in such a way that they do not contradict the patient's diagnosis.

Also, 16% of cases of fraud occur according to schemes related to failed repeated appointments and incomplete attendance at treatment courses:

Failed re-receptions. According to statistics, most patients miss repeated appointments. This has become a new field of activity for LPU: even if a person did not come to a second appointment, the insurance will receive a bill for him. 100% attendance during treatment with the course. Patients rarely attend all sessions from the prescribed treatment course. Usually out of 10 sessions, 3-4 are skipped. However, according to the studied accounts, from 90% to 100% of patients in them go to all 10 sessions without skipping.

The most obvious fraud occurs in regional clinics. Moreover, this is relevant both for the eastern, northern, and southern regions. So, many clinics prescribe tests for chronic diseases of the digestive tract to absolutely all patients who have treated pain in the abdomen, while in real practice they are needed only in 40% of cases.

Almost all insurance companies implement in their infrastructure IT- solutions based on - MLalgorithms that allow early identification of services that do not correspond to the diagnosis. Thanks to this, insurance companies reduce their losses. However, it is clear that this has spurred the development of new fraudulent schemes. In search of fresh "solutions" for overstatement, clinics began to bill for non-existent services or expand diagnoses in order to refer patients for tests that they do not need. At the same time, most cases of fraud look clinically justified: LPUs disguise them as ordinary, unremarkable sets of services, thanks to which insurance companies easily coordinate them, - said the Yuri Kuvshinov CEO of Mains Lab.

Note that overbilling fraud is not a new story in world practice. Globally, fraud in the VHI segment accounts for 10% to 20% of all services provided by clinics. For example, in Saudi Arabia, all major players in the market, along with the medical validity department, have independent anti-fraud units. For this country, fraud is a problem comparable to overtreatment. Insurance companies are actively fighting it to the point that they arrange test purchases: specialists go to clinics, pretend to be patients and watch how doctors behave.

The study was conducted using the IT solution MainsLab on the basis big data of the bills issued by the top 10. insurance companies Russia

The general director of the Novgorod medical center "Alternative" received 4.5 years in prison for fraud with compulsory medical insurance

On July 25, 2023, the Novgorod District Court passed a verdict against the general director of MC Alternative LLC Nadezhda Ulyanova and employees of the medical center Ekaterina Levina, Andrei Babenko, Anna Lisogor, Maria Konovalova. They were convicted of fraud as part of an organized group, using their official position, on an especially large scale. Read more here.

Hospital in Vladivostok fined for paying salary to PR-specialist from compulsory medical insurance funds

Vladivostok Clinical Hospital No. 1 was fined 220 thousand rubles for paying salaries to a PR specialist from the funds of the Territorial Compulsory Medical Insurance Fund (TFCMI). This became known on March 13, 2023. Read more here.

2022: Barnaul revealed an insurance fraud scheme for 9.5 million rubles by doctors of the city hospital

In September 2022, the third department for the investigation of especially important cases of the Investigation Department for Investigative Committee of the Russian Federation the Altai Territory opened a criminal case on the grounds of a crime under Part 4 of Art. 159.5 of the Criminal RUSSIAN FEDERATION Code (fraud in the sphere, insurance that is, theft of someone else's property by deception regarding the occurrence of an insured event, as well as the amount of insurance compensation payable in accordance with the law or an agreement to the insured or other person committed by an organized criminal group).

Three doctors of one of the state Barnaul hospitals of the Altai Territory are suspected of insurance fraud, the damage from which exceeded 9.5 million rubles. According to the investigation, doctors organized fictitious hospitalizations and issued fake certificates of non-existent injuries to those insured against accidents and diseases in order to receive insurance payments. Doctors, as well as an unemployed resident of the region suspected of organizing a fraudulent scheme, were detained.

In Barnaul, revealed the insurance fraud scheme for 9.5 million rubles by doctors of the city hospital

As follows from the materials of the case, at least 14 people participated in an organized criminal group, who from 2017 to June 2022 issued policies for accidents and diseases in more than 10 insurance companies, and then imitated insurance cases to receive refunds: they claimed severe head injuries and provided fake certificates.

{{quote 'In their appeals, they reported that they fell, slipping in the bathroom, or on the street, announced a fall in the cellar, from the roof of the garage, and also just being in the apartment. The declared diagnoses are open craniocerebral injuries, fractures of the base of the skull, bruises of the brain, said Svetlana Ardabyeva, deputy director of the security department of the Soglasie insurance company. }} The investigation found that all members of the group were related, and the doctors who participated in the conspiracy indicated in the documents the same diagnoses to all accomplices that were untrue. With the exception of the organizer of the group and the doctors who issued fictitious medical documents, who by the end of September 2022 are awaiting the completion of the investigation in the pre-trial detention center, the rest of the defendants in the case are under recognizance not to leave.^[1]

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