In one year, 2.2 million activations of automated control rules, prevention of the submission of claims with an indicative value of approximately €200 million, offsetting and corrections of €19 million, 46 administrative fines and termination of two provider contracts.
Artificial intelligence, advanced data analysis tools, and checks even on the photos used to document health services.
A special committee was set up by the Board of Directors of the Health Insurance Organization in order to draw up and implement a specialized plan for the management of abuses in the GHS.
Stratis Mattheou, chairman of this committee, in an interview with "F", presented the interventions of the HIO, explaining that the audits are no longer limited to the examination of compensation claims, but extend to the use of new technologies to identify unusual practices.
A tool is already being piloted to look for the possible reuse of photos to document different services, while additional data analysis and artificial intelligence capabilities are being developed.
At the same time, the Organization is moving in the direction of stricter penalties and higher administrative fines, with its board of directors having approved a relevant amending bill.
Under the microscope, among other things, unnecessary referrals, excessive use of tests, incorrect coding and requirements without sufficient documentation, with particular importance in inpatient care controls.
"Every resource that is protected remains available for the needs of patients," he stressed, underlining that addressing abuses is directly linked to the quality of care and the sustainability of the System.
Under the microscope examinations, referrals and hospitalizations
The HIO audits extend to the entire range of services provided through the GHS. The focus is on practices that may lead to unjustified use of the System, with particular attention to the field of inpatient care.
"The controls cover laboratories, pharmacies, hospitals, doctors as well as other health professionals. Unnecessary referrals, excessive use of tests, incorrect coding, and requirements without sufficient documentation are considered. Inpatient care is of particular importance, due to its financial size. Each finding is evaluated and investigated, so that the measures are based on documented findings."
Artificial intelligence and controls even on photos
"We combine automated rules, pre-payment sample checks, and targeted investigations. At the same time, advanced data analysis and artificial intelligence tools are being developed to detect unusual behaviours."
The first phase, which concerns the technical infrastructure and the reporting environment, "has been completed", while, "individual tools have been delivered and are being evaluated and at the same time a pilot tool is also being used to identify possible reuse of photos to document different services".
"Technology supports the investigation and better targeting of controls. Particular emphasis is placed on the utilization of expertise from abroad."
Specifically, "the Organization is strengthening the mechanisms for controlling and dealing with abuses with partnerships with mature health system bodies and participation in international networks for the exchange of knowledge and know-how. At the same time, the findings of the audits are used to review and improve rules and procedures, with the aim of preventing similar incidents in the future."
Audits on 855,000 receivables – Corrections of €19 million
The results of the audits carried out in 2025 reflect, according to Stratis Mattheou, the extent of the HIO's interventions, "but also the amounts resulting from the process of examining compensation claims".
"In 2025, approximately 855,000 compensation claims were audited, with a total value of approximately €181 million. The audits led to offsets and corrections of approximately €19 million."
At the same time, administrative fines were imposed in 46 cases and two provider contracts were terminated.
"These results reflect the systematic effort of the Organization to protect the resources of the GHS. The utilization of the findings guides the next interventions of the Organization and the abuse committee of the HIO with the aim of more effective prevention of abuses, targeted controls and the upgrading of the health services provided."
For the HIO, said Mr. Mattheou, "this progress is the basis for the continuous strengthening of control and accountability mechanisms".
What does the €200 million mean to averted claims
Of particular interest is the amount of approximately €200 million. related to claims that have been prevented. Mr. Mattheou analyzed what exactly this amount represents and why "it should not be confused with amounts recovered or with proven cases of fraud".
"This is the indicative value of incorrect or impermissible claims whose submission was prevented through the automated rules of the Information Technology System."
In 2025, "the rules were activated about 2,2 million times. The amount concerns prevention and differs from the amounts recovered or adjusted. Also, the prevention of a claim does not automatically constitute a finding of fraud."
Message to beneficiaries: No to pressure for unnecessary exams
Stratis Mattheou did not fail to emphasize that the effort to limit abuses does not exclusively concern health service providers.
"The rational use of the services of the GHS presupposes the responsible attitude of the beneficiaries as well. Receiving services, conducting medical examinations, issuing referrals and administering treatments must be based on documented medical need and the scientific judgment of health professionals."
In this context, "beneficiaries are asked to respect the clinical evaluation and refrain from exerting pressure for services that are not considered medically necessary. This responsible attitude contributes to the protection of available resources and to ensuring timely and equal access to the necessary care for all."
Equally important, he said, "is the active participation of the beneficiaries through the submission of opinions, suggestions and complaints to the Organization. Feedback from their experience is a valuable source of information, which the HIO uses to identify problems, investigate possible irregularities and improve procedures and services provided."
Tougher penalties and higher fines
In order to develop and strengthen the control mechanism, the HIO is also promoting legislative changes, which, among other things, provide for stricter penalties and a longer period of time for the offsetting of amounts due.
"The board of directors has approved an amending bill for harsher penalties and higher administrative fines. An extension of the period of time within which the Agency can offset amounts due is also foreseen. Promoting these changes will strengthen the available means of dealing with infringements."
"Every resource that is protected remains available to patients"
"To ensure that the resources of the GHS are used for the real health needs of the beneficiaries. Abuses burden the System and affect the rational allocation of available resources. Addressing them is a constant priority of the HIO and is directly linked to the quality of care and the sustainability of the GHS."
