€19 MILLION RECOVERED FROM AUDITS IN GESY - FINES OF €200,000. 80 ADMINISTRATIVE INVESTIGATIONS AND ONE CASE TO THE POLICE IN 2025 - Filenews 7/3 by Marilena Panayi
10% of the total compensation paid by the HIO to health service providers in 2025 passed an audit with the Health Insurance Organization proceeding with adjustments and offsetting of compensation amounting to €19 million, conducting dozens of investigations and imposing fines totalling €200,000.
"The process is uninterrupted and daily," the director of the Organization told "F". Konstantinos Panayides, stressing that "the control system is constantly being evaluated, upgraded and becoming more flexible".
In total, in the past year, almost 5% of all claims for compensation submitted were audited. "This percentage corresponds to 10% of the total amount of compensation paid by the HIO in 2025. In real numbers, that is, we are talking about a very large volume of hundreds of thousands of claims, which went through the audit and a not insignificant amount of money for which we checked whether it had to be paid."
Through the control mechanisms of the HIO, said Mr. Panayides, "the 850,000 claims corresponding to compensation of €180 million were checked. This audit identified problems in claims totalling €19 million, which the Agency recovered after offsetting and adjusting compensations." That is, "through the methodologies we apply, we had an indication of a number of claims that may have been suspicious. We proceeded with an audit and the audit found that claims of €19 million that had been paid, should not have been paid and we recovered the amounts."
The process of adjustments and offsetting, explained Mr. Panayides, "is carried out in cases where the claim is wrong, without necessarily suspecting an attempt to defraud the System and does not concern other administrative or even criminal offenses" and "it is worth saying that the €19 million concerned more than 100,000 transactions within the GHS".
In addition, he said, in 2.2 million cases, the system itself came and prevented the submission of claims worth almost €200 million "because the system itself, through the rules that we are constantly enriching, detected errors before they were paid. These providers were automatically informed, after their request was prevented and some proceeded with the necessary corrections or some did not revert to a claim again. This, however, is something that we cannot identify. The important thing and what we must keep in mind is that we were able, through the system, to identify 2.2 million claims whose registration would not have been allowed and was prevented."
€200,000 fines and 81 investigations
During 2025, said the competent director of the HIO, the Organization, either following a complaint, by providers or beneficiaries, or through the indications of the reports we are preparing, proceeded with an administrative investigation in a total of 81 cases. These cases concerned the possible commission of administrative or even criminal offenses.
"In 46 cases, after the investigation, fines totalling €200,000 were imposed. In two cases, the contract was suspended and one case was referred to the Police."
The imposition of penalties, said the director of the HIO, "is announced almost every month in order to keep both providers and beneficiaries informed of the actions taken by the Organization in order to prevent or reduce fraud and possible abuses within the System". With these data, "it is easy to understand that the competent directorate of the HIO is constantly working, monitoring the data and where an issue arises, we make our interventions". The amounts recovered, he added, "return to the GHS Fund".
Hospital admissions rate not justified
The audit in the GHS is carried out on the basis of three specific pillars: Prevention, detection and response.
"Prevention includes, among other things, the continuous enrichment of the Information System with rules for submitting claims, the publication of the controls carried out, the publication of the penalties imposed, the continuous updates of our providers, etc."
Also, "a very good tool is to inform the beneficiaries, either by email or by text message about the services they have received, because in this way we give the opportunity to those who detect an error, to inform us and proceed, if necessary, to investigate.
As far as detection is concerned, "we have the daily sample checks which give us indications. We also apply on-site inspections to GHS providers, especially in hospitals because there the entries in the IT system are compared with the actual data in the hospitals' records, while the institution of the admissions supervisor has also been implemented, which helps us monitor whether patient admissions to hospitals are justified. It must be said that the control so far shows that a percentage of imports are not justified and could be avoided."
The third pillar is the treatment "where, after the necessary investigation, fines are imposed, contracts are suspended, offsets are made or we even refer cases to the Police".
Use of AI and cooperation with foreign experts
The IT system, explained Mr. Panayides, "has the ability to produce reports to detect strange behaviours. At the same time, we are in the process of developing an advanced application, which will also use artificial intelligence (AI) functions and through sophisticated statistical approaches and models will provide the Organization with the possibility of more targeted indications that will help evaluate data for the start of investigations." In this context, "we are developing various models to identify separate issues related to referrals, medicines, inpatient care, primary care, etc. Through these models, specific indicators are monitored for which the system itself comes to inform us that something is emerging that does not fall within the expected data. For example, a doctor registers a much higher number of visits than other doctors of the same specialty, prescribes much more, and so on."
At the same time, "we developed some other applications, with the use of Artificial Intelligence, which help even more. The example of the doctor who was fined in January is typical. This doctor registered the same photo and claimed compensation for different patients. The system detected him. It must be said that we are working with the European Network to Tackle Abuse and Fraud in Health Systems, which is a Non-Profit Organization in which similar Organizations to the HIO participate, through which know-how and experiences are exchanged."
Also, "a partnership with the UK health system is now beginning, where an independent Anti-Fraud Authority operates. A memorandum of cooperation will be signed with various actions such as, for example, education and the transfer of know-how."
