What inspectors (pretending to be patients) of social health insurance are (not) allowed to do

Insurance Alert

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Against severe resistance of the medical profession, the social insurance agencies may send out inspectors pretending to be patients (in other industries also described as "mystery shoppers") to doctors' offices and hospitals since the beginning of 2016 in order to reveal irregularities. For such inspectors, however, legal limits exist.

Vienna – This phenomenon is known mainly in the private sector so far. Trained observers act as test shoppers in a company and rate the quality of the services provided by this company on the basis of a defined set of criteria. These test shoppers (also known as "mystery shoppers") thereby naturally do not disclose the true nature of their mission. After all, the tested service shall be provided and evaluated without any influence.

Since the beginning of 2016 also hospitals and doctors in Austria need to expect the visit of patients, who are in fact not necessarily ill. Since 1 January 2016 the Austrian social insurance agencies are entitled (because they are obliged by law) to inspect the proper conduct of the practice of their contractual partners – i.e. doctors and healthcare facilities (e.g. hospitals). The social insurance agencies may for this purpose use specifically issued E-cards and inspectors (commonly also called "false-" or "test-patients").

This novelty was introduced against the severe resistance of the Austrian Medical Association; the Medical Association considers its profession under general suspicion and warns that false patients would impair the mutual trust between doctors and their patients. However, its protests were left unheard.

Doctors and hospitals seem to have not yet full clarity under which circumstances they can expect such inspectors to appear and what must be considered in such cases.

Suspicion or random inspections

Inspections of contractual partners by the social insurance agencies are not admissible unconditionally. Inspections may be conducted either upon a reasonable suspicion that the respective contractual partner performs procedures not in conformity with the law or contract or in the course of random inspection (irrespective of a suspicion) based on an annual inspection plan.

A reasonable suspicion exists if specific information indicates an irregular conduct of billing matters by the contractual partner. Suspicions may arise for example if sick leave certificates are issued very often or irregularities in the billing of services occur in a doctor's office.

The annual sample plan is, of course, not publicly accessible. This plan shall, however, be set up in such way that one contractual partner is not affected multiple times within a short timeframe.

Several check points

As regards to the content of an inspection a comprehensive check list exists. This list reaches from controls of the provision of services in conformity with the contract, sick notes, referrals and medical prescriptions, goes on to inspections of waiting times, opening hours of doctor's offices and hospital out-patient departments as well as the use of examination devices – to the extent such devices were publicly financed or co-financed – up to the control of appointments, the relation of services covered by the health insurance and private services as well as the selection of therapies in view of economical treatment.

There are, however, even for – hidden – inspections itself limitations by law. It is in any case considered inadmissible if a mystery patient induces a contractual partner or facility to undertake illegal actions. The same applies for putting pressure on a physician, i.e. by asking persistently or by arousing pity.

The use of findings gained by using such methods is considered illegal. The use of such illegal methods would be of particular importance if the contract with the social insurance agency should be terminated as a consequence of finding irregularities.


The article was originally published in der "Der Standard" and is reproduced with permission.

View the original article in German