Customer magazine

Cases of fraud and how we uncover them

Wherever money is involved, you will also find fraudsters. They tweak, manipulate and invent invoices in order to cheat insurance companies. A scam is exposed at Helsana on a daily basis. Our two fraud experts Sébastien Cosandier and Christophe Banderet explain the different methods that fraudsters come up with – and how we get wise to their tricks.

Sherlock Holmes
A couple more thousand francs on your account – why not? This was the very thought that likely went through the head of Mr Z.* when he submitted an invoice from a Cameroon hospital to Helsana. Our employee became suspicious: four weeks in hospital with malaria? That seems unusual for a young man in good health. What treatment and medication did the patient receive? Were there any complications? In the absence of a detailed invoice listing the services provided, it is impossible to say. Enquiries with the hospital reveal the following: the customer was never there. And the invoice? A forgery based on an authentic bill.

“It is not always the case that we uncover an attempted instance of fraud so quickly”, explains Sébastien Cosandier, who heads up the International Centre. Some 18 specialists check and process several hundred invoices from abroad here every day. Each employee is multilingual and has international roots, meaning that they are familiar with the foreign healthcare systems. “This helps us in assessing suspicious cases and communicating with people around the world”, says Cosandier.

Searching for evidence with x-rays

Unlike Swiss invoices, which are automatically checked by a system at Helsana, the International Centre has to check each document manually. Are the services plausible? Are they valid, appropriate and economically viable in accordance with the Federal Health Insurance Act? “We can only check this if we have the relevant details on the invoice”, explains Cosandier. “However, we often only receive hand-written receipts”. These are easy to manipulate: the insured person changes the amount by hand so that he or she is paid out a higher sum. This means that EUR 20 suddenly becomes EUR 720. According to Cosandier, however, such forgeries have no chance of success: “We place suspicious invoices in our special scanner, a type of x-ray machine, which makes changes visible”. Exaggeration is also a popular trick: a routine case suddenly becomes a complex illness. This was what happened with Ms B., who ate a chicken sandwich in the heat of Egypt and ended up with salmonella poisoning. She sent us an invoice for six days in hospital, three days of which were supposedly spent in intensive care. There were also costs for extensive tests, ranging from computer tomography and ECGs to ultrasound. Total costs: CHF 5,500. “We do not doubt that the young woman in question spent time in hospital”, says Cosandier, “but the invoice had been embellished by the hospital, likely at her request”. The hospital refused to provide Helsana with any details. It was also involved in a second dubious case. “This strengthened our suspicion of insurance fraud”, added Cosandier. Helsana thus only refunded those costs that were medically justified.

Made-to-order medical reports

We see bogus invoices and purchased medical reports time and again. This was also the case with a clinic in Sri Lanka, which Mr A. visited due to a skin infection. And this resulted in a two-week stay? According to Cosandier, outpatient care would have been appropriate here. “The information provided by the hospital staff and the customer’s payment receipts were contradictory”, he explains. Investigations on site revealed that the small clinic had hardly any capacity for inpatients. And why was there no medical follow-up check in Switzerland? Are they any scars? The customer won't answer. “As nobody wanted to provide an answer to our questions, we ultimately had to reject the invoice”.

His colleague Christophe Banderet is also familiar with fictitious services appearing on statements. He is leading the battle against fraud at Helsana here in Switzerland. “Helsana processes 14 million invoices per year, a large portion of these on an automated basis”, he reveals. “This makes it even more difficult to identify fraudulent cases”. We recognise new fraud patterns by means of data analysis, for example, as well as thanks to the network we maintain with industry colleagues and agents. Banderet: “Each case entails detective work: collect, interpret and collate information”.

Fiduciaries of the insured

Helsana looks into all suspicious cases. Two customers recently complained about an eye laser centre. It had supposedly billed for services that it had never provided. And our research revealed even more: the optician is also 30 percent more expensive than his local counterparts. “We view ourselves as a fiduciary of our customers”, says Banderet. “Those who don’t invoice correctly are making money at the expense of premium payers”. However, appearances can often be deceptive and customers are unable to interpret the details on the invoice. The doctor failed to cooperate despite all of the facts and claimed that the affected customers were suffering from dementia. “We will likely take legal action against him”.

Bringing about criminal charges, however, is not always the best way to stop fraud. This is especially true in connection with offences involving smaller amounts. Helsana prefers to talk to those involved directly. “Handling the case via legal channels generally takes longer. We place an emphasis on retrieving the defrauded sum and changing the conduct of the individual in question”.

Daily allowance insurance as a cash cow

It is not only insured persons and doctors who sometimes err – employers are also known to misuse insurance cover as a cash machine. Such an instance was seen with a company that reported an unusually high number of cases of total incapacity to work as a result of illness. This involved daily allowance totalling tens of thousands of francs. Upon inspecting one of its certificates of incapacity for work, it turned out that the employee in question was no longer employed. His employment contract had only lasted three days. We also found out that employees who had been signed off sick were playing for the local football club during their absence – the team’s trainer was also employed at the company in question at the same time. Suspicious: he had purchased several former professional players from abroad. Where is a small club like this getting the money from? Is this a case of systematic insurance fraud with forged medical certificates? “At the moment, this is just a suspicion”, says Banderet. “We only intervene when we have clear evidence”.

Fraud scam with tablets

You can also make money with medication. For example, it can be sold on at expensive prices. This was likely the intention of one 38-year-old insured person upon purchasing addictive sleeping aids and sedatives in a volume 30 times greater than the recommended dosage. “No person could survive taking so many sleeping tablets”, states Banderet. The prescriptions were obtained from two different doctors and the customer purchased the medication at two different sites. In doing so, he obtained medication worth more than CHF 40,000. And: he was not alone in taking this course. Banderet: “Thanks to an individual case, we were able to expose a new fraud scam”.

But how does Helsana handle such cheats? Termination of supplementary insurance? Criminal proceedings? “We primarily seek a solution that benefits the community”, says Christophe Banderet. Here, medication restrictions are preferable to a trial, for example. “In an instance such as this, all of those involved should learn something new and have their awareness raised about similar cases”. Sébastien Cosandier shares this opinion: “Our efforts aim to ensure prevention rather than repression. That is far more sustainable”.

Text: Daniela Schori

*All cases are based on actual events but have been anonymised for legal reasons.