Estonian Health Insurance Fund starts investigating possible cases of fraud

  • 2020-06-25
  • BNS/TBT Staff

TALLINN - The possibility to open a certificate for sick leave yourself, receiving compensation for the first three days of illness and the requirement to remain in quarantine at home in case of suspicion of COVID-19 may have tempted some people to deceive the system, the Estonian daily Postimees writes.

Possible misuse forced the Estonian Health Insurance Fund to check the sick leave certificates issued during the emergency situation. Although the sick leave certificate is opened for the individual, the Health Insurance Fund plans to recover the money from the companies in case of fraud and the authority is also promising to review the behavior of doctors. In two months, 50,000 more sick leave certificates were opened than last year, and the Health Insurance Fund started the inspection of the certificates with machine inspections.

First, the Health Insurance Fund compared how many of the 130,000 people who received salary compensation were on sick leave at the same time. You cannot be sick and going to work simultaneously. "We have managed to manually review 536 sick leave certificates that seemed suspicious to the machine, whether the person also received income subject to social tax, that is wage compensation, at the time," Health Insurance Fund management board member Pille Banhard said.

To date, out of these 536, the Health Insurance Fund has identified 140 people who received wage compensation from the Unemployment Insurance Fund and sick leave compensation from the Health Insurance Fund for the same period. In this case, both the Unemployment Insurance Fund and the Health Insurance Fund can claim back their benefit. If one of them receives the money, the other has no grounds to claim a repayment.

Secondly, the Health Insurance Fund found those employers with a very large number of employees on sick leave at once. This may have suggested fraud on the part of the employer. "We found 110 companies, at the moment we have been dealing with 14 of them," spokesperson for the Health Insurance Fund Evelin Trink said, not disclosing the names of the institutions or the amount of benefits. "However, the certificate of incapacity for work is given by the doctor to the person. If we find that the unjustified payment was due to false information provided by the employer, we will demand a refund from the employer for the sick pay," she added.

Thirdly, the Health Insurance Fund plans to check doctors. "We will definitely look at the behavior of doctors and if it turns out that the certificate of incapacity for work was issued unreasonably, we will also submit a claim to the medical institution, if necessary," Trink told Postimees.

However, it is difficult to determine the need for sick leave ex post. Rain Laane, chairman of the board of the Health Insurance Fund, stated already in mid-April that it is very difficult to prove later whether a person was actually sick at home, taking care of a sick next of kin or not.

Le Vallikivi, head of the Estonian Family Medicine Association, said that it is easy for a person who does not want or is not allowed to go to work to deceive a family doctor if they wanted to lie about being ill. Unless a person has previously given reason to suspect, family doctors generally trust their patients. "The coronavirus changed our approach -- no one with signs of an upper respiratory viral infection was allowed to go to work, kindergarten or school," she said.

The Health Insurance Fund will continue to manually review problem sick leave certificates. "We are comparing medical documents and bills, asking doctors for explanations, if necessary," Banhard said. "We will continue to work, but it is too early to say how many recoveries we will make in the end."

All sick leave certificates will be processed by the end of the year at the latest.

Around two weeks ago, the National Audit Office said in an audit report that the Health Insurance Fund's control activities fail to systematically prevent or detect the misuse of health insurance funds. According to Laane, a fine could completely eliminate medical care away from some areas. The Health Insurance Fund decided to keep quiet about the names of the health care institutions that defrauded the authority of money, because a lot of time had passed since the violations. Like treatment money, sums paid for sickness benefits come from citizens' pockets and the public has the right to know the names of the institutions that have misappropriated money from the Health Insurance Fund, be they service providers or employers, Postimees writes.