Billing Fraud in the Healthcare Sector: Doctors & Nursing Services – Overview, Typical Scenarios, Defence Strategies

Short Overview

Billing fraud in the healthcare sector affects both contract physicians/medical care centres (MVZ), private medical billing (GOÄ/GOZ), and nursing services. Under criminal law, the assessment is usually based on the elements of fraud (§ 263 StGB) – deception, error, disposition, and financial loss. Special aspects arise from the social law remuneration system (GKV/KV/EBM, standard service volume) and the strict formal approach to billability. After a conviction, legal remedies such as appeal or revision may be considered.

1) Contract Physicians & Medical Care Centres (GKV)

• System logic (KV/total remuneration/EBM): Billing is carried out against the Association of Statutory Health Insurance Physicians (KV); audits are often highly formalised. Since 2009, fixed prices apply within the standard service volume; outside of this, scaling may apply.
• Typical deception scenarios: Non-indicated or non-standard services, incorrect assignment of billing codes (GOP), splitting across time periods, non-delegable services billed as personal, kick-backs not disclosed.
• MVZ specifics: Formal billability is decisive; in cases of status-related violations (e.g. inadmissible participations), damage may be assumed even if treatment was medically correct.

2) Cooperation in the Healthcare Sector

Forms of cooperation and organisation (practice networks/MVZ) are permitted, but must formally comply with professional and social law requirements. Violations can eliminate billability – relevant for deception and financial loss in overall assessment within medical criminal law.

3) Private Medical Billing (GOÄ/GOZ)

• Deception scenarios: “Phantom services,” unjustified increase factors, services not personally performed, laboratory kick-backs.
• Economic assessment: In private billing, the payment claim according to GOÄ is central; lack of billability may be considered financial damage.

4) Nursing Services

Misrepresentations about qualifications or scope of services to health insurance funds can constitute fraud. If contractual qualification requirements are not met, billability regularly ceases – resulting in damage equal to the remuneration received.

Defence Strategies & Practice

• Examine formal requirements & billability precisely (delegation, billing codes, qualifications, contractual framework).
• Strengthen documentation & indication; individualise justifications under GOÄ/EBM.
• Challenge financial loss economically (overall assessment, reference dates, alternative causes).
• Procedural strategy: Explore early termination options (§ 153a StPO, § 170 II StPO); if a judgment is issued, prepare appeal or revision in time.

FAQ about Billing Fraud in Germany

What are typical billing fraud scenarios?
Typical cases include non-indicated or inflated services, incorrect billing codes, inadmissible delegation, kick-backs, or formally non-billable MVZ structures.

How is “financial loss” determined?
In statutory health insurance cases, strict formal billability applies. In private billing, the GOÄ claim is central; lack of billability can mean financial damage.

What legal remedies exist?
Against local court judgments, appeal (with new factual hearing) or leap revision is possible; against higher court judgments, revision is available as legal control.

Is termination of proceedings possible?
Yes, depending on the case, via § 170 II StPO (no charges) or § 153a StPO (termination with conditions).

Does Buchert Jacob Peter also defend in white-collar and healthcare-related cases?
Yes, our specialist criminal defence lawyers represent clients in healthcare fraud, tax cases, and complex white-collar crime proceedings.

Contact us – Your Specialist Lawyers for Criminal Law in Frankfurt am Main and throughout Germany

• Attorney Dr. Caroline Jacob, Specialist Lawyer for Criminal Law
• Attorney Frank M. Peter, Specialist Lawyer for Criminal Law
• Attorney Dr. Sven Henseler, Diplom-Finanzwirt (FH)
• Of Counsel: Prof. Dr. Frank Peter Schuster
• Cooperation Partner: Tax Advisor and former Tax Investigator Frank Wehrheim

Our law firm Buchert Jacob Peter has been working in Frankfurt am Main for over 25 years with experienced criminal defence lawyers. We represent our clients nationwide.

📞 Phone: +49 69 710 33 330
✉️ E-Mail: kanzlei@dr-buchert.de

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