September 2014

Beware of fraudsters!

Health insurers pay out over 30 billion francs in benefits in Switzerland each and every year. Where there are large amounts of money involved, fraudsters are never far behind. Read on to find out more about some of the scams they use and how Helsana stops them in their tracks.

Not everyone makes life as easy for anti-fraud investigators as the Swiss man who renovated the bathroom of his holiday home in Portugal and, without further ado, sent the invoice straight to Helsana.* «Either he did it by accident, or he was under the assumption that we wouldn't understand the Portuguese invoice», says Susanne Henseler, head of the International Competence Centre at Helsana. Eighteen of its 52 staff are specialists in insurance fraud and sift through invoices from abroad with a fine-toothed comb. The team speaks a total of 12 languages and commands a wealth of specialist expertise. This is the only way they can intervene in suspicious circumstances.

If a client has had a cyst removed from her breast in Brazil, for example, it is well worth taking a look at the case in closer detail. It is of course entirely possible that the procedure was necessary from a medical perspective, he explains. «But when invoices are received from countries where cosmetic surgeries are offered on every corner, we have to be more careful.» It is an unfortunately all-too-common occurrence that patients and doctors agree to disguise a breast enlargement as an emergency so that the health insurer covers the costs. And the suspicions prove correct: after telephone calls to the client as well as to the doctor in Brazil, their scam is blown.

In a coma on Facebook

Much more frequently, clients alter hand-written medical bills after the fact. Last year, several hundred forged documents were flagged for further investigation. Like when a Moroccan general practitioner issued a tourist an invoice of 46 dirhams for a routine examination, which the patient promptly settled on the spot in cash. Then, when back in Switzerland, the client added a one in front of the amount and three zeros after it. And suddenly, instead of a bill for five francs for a consultation concerning an upset stomach, Helsana was asked to transfer 15,800 francs. «With the help of a document scanner, similar to the one they use at customs, we can see precisely which figures have been added after the invoice was issued», explains Susanne Henseler.

Insurance fraudsters are extremely resourceful. Often they use personal contacts abroad to inflate their own bank accounts. A Helsana client kept referring acquaintances to the spa therapy unit of a hospital in her former home country of Croatia. In return, the doctor cut her a deal: he certified that the woman had been lying in his intensive care unit for a month – the first three weeks of which in a coma. Barely had she woken from her «coma» than the 43-year-old submitted a claim for over 80,000 francs. When the Helsana specialist began to dig a little deeper into the case, the hospital in Croatia couldn't locate the patient's file. Everything pointed to insurance fraud. An Internet search confirmed these suspicions: the woman had changed her Facebook profile picture while she was supposed to have been lying in a coma in hospital. Not all cases can be solved from behind a desk, however, elaborates Susanne Henseler: «When we have exhausted all avenues open to us, we can mobilise agents on the ground to take up the trail.»

Scamming some paid leave

However, invoices from abroad are no longer the only ruse used to defraud insurers. Often the sums swindled in Switzerland are several times higher. When an employee has an accident, the costs can quickly rack up: on the one hand, there are the treatment costs; while on the other, depending on the type of accident insurance the company has, Helsana may pay the employee's full salary during the full time they are away from work. «If an absence lasts for longer than six months, we always investigate the matter from the ground up," says Christophe Banderet, who heads up the anti-insurance fraud department at Helsana. «If the signs clearly point to insurance fraud, Helsana intervenes even earlier than this», he explains. For example, if a construction worker has an accident and is given four months' sick leave due to persistent back pain, this may seem plausible at first glance. What he has failed to tell his doctor, however, is that as an excavator operator he does not have to carry any heavy loads. This is a typical case: «The accident actually did occur, but patients use various tricks to draw out their return to work for as long as possible.»

It would be equally suspicious, for instance, if a banker with shoulder problems were to allege that they had been told to stay away from the office for several weeks because they are no longer able to use their mouse. In extreme cases Helsana even deploys detectives, who sometimes come across the most astonishing things: an employee in the service industry has been prescribed sick leave due to chronic migraines, but then stays up all night partying – what is wrong with this picture? «People who procure insurance monies by unjust means have to pay back the benefits received out of their own pockets.» In extreme cases, Helsana may even bring charges.

Good dose of tact and intuition

It is not only private clients that seek to deceive; so do service providers such as therapists, doctors, pharmacists and hospitals. «Since it is simply impossible to check every single receipt, we work with sophisticated statistical methods to track down the fraudsters.» Helsana knows, for example, that emergencies are a relatively rare occurrence for general practitioners. So if a doctor charges an emergency flat rate for every third case, this puts us on the alert and we contact the doctor. «Our system is very complex: we create a footprint for every service provider based on various parameters; if these parameters are exceeded to a noticeable degree, we set our investigations in motion.» Even when Helsana uncovers patterns that point towards fraud, a good dose of tact and intuition is still called for. «Clients, doctors, pharmacists, clinics and therapists make mistakes as well; there doesn't necessarily have to be malicious intent behind it», says Christophe Banderet.

«Whether abroad or at home, honest policyholders have to foot the bill for the financial losses caused by fraudsters», he continues. Thanks to our efforts, the number of cases of fraud has declined considerably in recent years – not least because word has got around how closely we are keeping an eye out for anything even remotely suspicious. As an independent company that has to compete in today's tough environment, we have a vested interest in keeping costs – and thus premiums – low. We do this in various ways, including through our ongoing war against fraud.»

* All cases are based on actual events; names have been omitted for legal reasons.

Text: Christian Schiller