Fake prescriptions for medication that patients never receive, fictitious care services and billing for trips that never existed: billing fraud has cost the KKH Kaufmännische Krankenkasse millions in damages.
In the two-year period 2024 and 2025, damage of more than eight million euros was incurred nationwide - the highest damage to date within two years, the health insurance company said. In the previous two-year period it was around 4.5 million euros. If you look at the last two years separately, the damage in 2025 was around 2.6 million euros, and in 2024 it was even 5.4 million euros.
Millions recovered
Fraud caused the greatest damage in the pharmaceutical sector - last year alone it was around 875,000 euros. Closely behind was outpatient and inpatient care at around 844,000 euros. The KKH received 605 new reports nationwide last year. Most suspected cases occurred in outpatient care and out-of-hospital intensive care before physiotherapy and physiotherapy. The most common scams: non-performance of services, unqualified staff and lack of approvals.
The KKH has been investigating suspected cases of fraud, corruption and forgery for a quarter of a century. “During this time, the tricks of the fraudsters in the healthcare system at the expense of the solidarity community have become more sophisticated and the greed for money has become greater,” said KKH chief investigator Emil Penkov. The investigators have demanded a good 1.3 million euros back in the past two years - with success.
Some mafia-like structures
So-called low-threshold services such as improvements in the living environment are particularly susceptible to fraud in care: This opens the door to fraudsters, said the lawyer. “In this area they operate with sometimes mafia-like structures – using shell companies, across federal states and even abroad.” In intensive care, fraudsters act “ice-cold” and sometimes life-threatening situations are possible – for example if those in need of care are cared for by untrained staff.
The frauds come as little surprise to most people: According to a Forsa survey commissioned by the KKH, around two thirds of those surveyed consider the German healthcare system to be susceptible to fraud - 22 percent even classify it as very vulnerable. Two thirds of those surveyed have also experienced fraud in the healthcare system themselves, for example when someone was not adequately cared for despite their level of care. A total of 1,002 people aged 18 to 70 were surveyed from July 24th to 27th.
Artificial intelligence in action
The health system is considered tempting for fraudsters because billions of dollars are being spent there: According to the umbrella association of statutory health insurance and social long-term care insurance, service expenditure nationwide amounted to around 410 billion euros last year. In 2022 and 2023 alone, health and nursing care insurance funds suffered damage of more than 200 million euros.
“The more closely knit and professional our joint network of investigators operates, the fewer loopholes remain for greedy criminals,” said Penkov. The KKH also relies on artificial intelligence to efficiently check large amounts of data - but only within the cash register. He called for political decisions to be taken so that the data can also be compared across health insurance companies. According to its own information, the KKH is one of the largest statutory health insurance companies in Germany, with around 1.5 million insured people and a budget volume of around 8.7 billion euros.
