Abwendung sozialrechtlicher Vermögenssanktionen als Abrechnungsbetrug?

Lucas Walker

doi:10.1628/978-3-16-200500-7

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Lucas Walker

Abwendung sozialrechtlicher Vermögenssanktionen als Abrechnungsbetrug?

Zur Übertragbarkeit der Ausklammerung geldwerter staatlicher Sanktionen aus dem Vermögensbegriff auf den Vergütungsausschluss in der vertragsärztlichen Versorgung

[Avoidance of Social Law Financial Sanctions as Billing Fraud? On the Transferability of the Exclusion of Monetary State Sanctions from the Concept of Property to the Exclusion of Remuneration in Statutory Outpatient Medical Care.]

2026. 320 pages.

forthcoming in June 2026

Studien zum Medizin- und Gesundheitsrecht (MGR) 23

DOI 10.1628/978-3-16-200500-7

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978-3-16-200500-7

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Summary

Anyone who deceives in order to avert state sanction claims does not commit fraud. Lucas Walker examines the transfer of this idea to billing in statutory medical care and argues that avoiding exclusions from remuneration under social law should not in every case be classified as billing fraud.

Lucas Walker examines the implications of excluding monetary state sanction claims from the scope of protection of Section 263 of the German Criminal Code (StGB) for fraud in the context of billing within statutory outpatient medical care. At the heart of the study lies the question whether exclusions of remuneration under social law should likewise be classified as sanctions and therefore fall outside the scope of the fraud offence.
Chapter 1 outlines the system of billing in statutory outpatient medical care and the prevailing interpretation of the elements of fraud in this context. The case law associated with the so-called »strictly formal approach« is critically assessed. While an impermissible conflation cannot be established, the undifferentiated reliance on social law evaluations leads to a shift in the protected legal interest, as it effectively introduces additional protected interests into the offence of fraud. The rigid application of the criterion of immediacy is also unconvincing, as it artificially separates economically connected services and fails to adequately reflect the value of medical treatment. A holistic assessment therefore appears preferable.
Chapter 2 discusses the established case law on the exclusion of state sanction claims (criminal fines, administrative fines, certain ancillary tax claims, and confiscation). Decisive factors are the absence of an economic purpose and the resulting lack of participation in economic transactions.
Chapter 3 examines whether this sanction-based reasoning can be transferred to exclusions of remuneration under social law. Such exclusions are tied to formal requirements and deny claims even where treatment was provided lege artis. They do not pursue economic objectives, but rather serve as disciplinary instruments aimed at protecting the statutory health insurance system, and are thus comparable to state sanctions. This applies in particular in cases involving anti-corruption provisions.

Table of contents:

Einleitung
A. Problemaufriss
B. Ziel und Zuschnitt der Arbeit
C. Gang der Darstellung

Kapitel 1: Status Quo des Abrechnungsbetrugs
A. Grundzüge des vertragsärztlichen Abrechnungssystems
B. Tatbestand des § 263 StGB
C. Bewertung der Rechtsprechung
D. Ergebnis Kapitel 1

Kapitel 2: Nichterfassung von geldwerten staatlichen Sanktionsansprüchen gemäß § 263 StGB
A. Entwicklung der Rechtsprechung
B. Bewertung der Rechtsprechung
C. Ergebnis Kapitel 2

Kapitel 3: Pauschaler Honorarausschluss als staatlicher sanktionsähnlicher Anspruch
A. Vollständiger Vergütungsausschluss in der vertragsärztlichen Abrechnung
B. Vollständiger Vergütungsausschluss als geldwerter staatlicher Sanktionsanspruch
C. Erstreckung auf weitere Leistungserbringer
D. Ergebnis Kapitel 3
Gesamtergebnis