Healthcare fraud detection — signals, damage and how investigation helps

Healthcare fraud in the Netherlands: a growing problem costing millions

Healthcare fraud is one of the fastest-growing forms of fraud in the Netherlands. From false personal budget (PGB) claims to phantom care and upcoding, the methods are becoming increasingly sophisticated while the damage to care institutions, municipalities and insurance companies runs into hundreds of millions of euros annually. According to the Scientific Research and Documentation Centre (WODC), the actual figures are likely even higher than officially recorded, as a significant proportion of fraud remains under the radar.

The problem extends beyond finances. Healthcare fraud undermines trust in the healthcare system and comes at the expense of vulnerable people who genuinely need care. Municipalities responsible for implementing the Social Support Act (Wmo) and Youth Act find their budgets under pressure from improper use. Health insurers see their claims burden rise, ultimately affecting the premiums all Dutch citizens pay.

For organisations that suspect healthcare fraud, acting swiftly and carefully is essential. A professional healthcare fraud investigation delivers legally admissible evidence that stands up before the court or regulatory authority.

Signals that indicate healthcare fraud

Healthcare fraud takes many forms. The Fraudehelpdesk receives thousands of reports annually relating to irregularities in the healthcare sector. The following signals are common and warrant further investigation:

• Disproportionate claims not in proportion to provider capacity
• Phantom care billed but never actually delivered to clients
• Upcoding where cheaper procedures are billed as expensive ones
• PGB funds spent on purposes other than care
• Double billing of the same care to multiple funding sources
• Identity fraud using BSN numbers or insurance details of others
• Unexplained explosive growth without logical explanation
• Demonstrable quality issues while full billing continues

Recognising these signals often requires specialist knowledge. Not every irregularity constitutes fraud — sometimes there are administrative explanations — but when multiple signals converge, a thorough investigation is justified.

How SAJ Recherche investigates healthcare fraud

At SAJ Recherche, we conduct healthcare fraud investigations in compliance with the Dutch Private Security and Investigation Agencies Act (Wpbr) and the General Data Protection Regulation (GDPR/AVG). Our investigation is focused on establishing objective, legally admissible facts.

The approach to a healthcare fraud investigation typically follows these steps:

• Intake and file assessment to define research questions with the client
• Administrative investigation of billing data, client files and financial records
• OSINT investigation into care provider backgrounds and business structures
• Surveillance when care delivery or provider activities are in question
• Witness statements from patients, employees or other relevant parties
• Reporting in a factual report suitable for legal proceedings or enforcement

All investigations are conducted under our POB licence 8779, issued by the Ministry of Justice and Security, ensuring the investigation meets legal requirements and that collected evidence is admissible.

Practical example: PGB fraud at home care organisation

A mid-sized Randstad municipality suspected fraud at a home care organisation billing substantial PGB-funded amounts for over twenty clients while actual care delivery appeared lacking. Our administrative analysis showed the declared volume was impossible given the limited staff, and surveillance confirmed no care providers were present at several addresses during billed hours. OSINT investigation revealed the director was siphoning care funds into private property investments via multiple entities. Based on our report, the municipality terminated the agreement, initiated a recovery claim and filed criminal charges. Clients were transferred to a reliable provider.

Prevent healthcare fraud from going undetected

Healthcare fraud is rarely a one-off incident. The longer investigation is delayed, the harder it becomes to map the full extent and the smaller the chance of successful recovery.

Suspecting healthcare fraud at your organisation? Contact SAJ Recherche for a confidential consultation.