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Healthcare fraud: How to prevent healthcare providers from making mistakes?

Fraud in the healthcare sector is unfortunately still too common and is a pressing issue given that care must be available at all times to the vulnerable citizens who need it. How do you prevent healthcare fraud from happening?

What is healthcare fraud?

Healthcare fraud involves acting in a misleading manner within the healthcare sector. This includes deliberately acting contrary to the rules, both for one’s own and others’ gain.

Such fraud is distressing because the people who need care should always have access to proper quality care. Moreover, it should be possible to rely on the fact that the money from taxes and health insurance premiums is used for the actual delivered care.

What type of healthcare fraud is most common and where?

To manage fraud in the healthcare sector more effectively, nine partners – including the Dutch Healthcare Authority (NZa), Zorgverzekeraars Nederland (ZA), The Association of Netherlands Municipalities (VNG), Tax Administration, and Fiscal Intelligence and Investigation Service (FIOD) – are working closely together under the name Informatie Knooppunt Zorgfraude (IKZ). Together, they investigate and share reports of healthcare fraud.

Their report ‘Signalen en fraude in de zorg 2020’ (link only available in Dutch) shows that there are frequent suspicions of fraud in district nursing, individual guidance, dental care, and mental health care (GGZ). For example, more hours were claimed than were actually spent on care, but fictitious clients were also reported, care was of insufficient quality, and diplomas and signatures were forged.

Examples of healthcare fraud are not isolated

In addition, the report discusses several cases, in which healthcare fraud was suspected and eventually detected. For example, it includes a case about a healthcare institution that went bankrupt after an investigation of alleged fraud. The management then continued under the flag of a new healthcare institution, where exactly the same thing happened: alleged healthcare fraud and recruiting the same clients who had previously received care.

Unfortunately, the case above does not stand alone. Research conducted by the IKZ into the history of 53 healthcare executives involved in fraud cases found that 30 of them had criminal records. The 2019 study focuses on known fraud cases, highlighting the history of the directors involved.

What are the consequences of healthcare fraud?

Apart from the financial damage caused by healthcare fraud, there are other damaging consequences:

  • Reputational damage, for example, is just as drastic if not more because it significantly challenges trust in the healthcare sector.
  • In addition, patients can be put at risk when there is inadequate quality care, for instance by unqualified healthcare providers.
  • Finally, the behavior of fraudulent healthcare providers casts a shadow on well-intentioned and well-trained healthcare providers. 

How can healthcare fraud be prevented?

Current legislation and regulations, such as the Healthcare Quality, Complaints and Disputes Act (Wkkgz) and the duty to verify (vergewisplicht) show that the healthcare sector is checking more strictly for healthcare quality and integrity. This is a good first step, but healthcare institutions can also take action themselves to continuously guarantee the quality of their care.

Employment screening is already a common practice in most sectors. By screening new employees upon the start of employment, you can be sure that you are hiring the right people to strengthen your teams. In addition, in-employment screening ensures that the quality remains high. But how does a healthcare institution set up an appropriate screening process that not only meets its own needs but also complies with current laws and regulations?