After being tapped by the Court of Auditors, Health Insurance began work to combat fraud in the fall of 2020. More than 18 months later, it is delivering its first assessments. Give them? “Better knowledge of financial losses, by type of risk, to better detect and sanction them, but also consolidate all actions to prevent fraud”, explains the body
In 2020, the Court of Auditors recalled that in 2019, the Health Insurance estimated at € 1 billion the amount of irregular bills paid to professionals and healthcare facilities, “But this amount does not include stays in public and private non-profit health facilities.” It is therefore clearly underestimated. »
How to track down fraud?
Looking at all the categories of benefits, it is a complex job. The Health Insurance first performed «A comparative analysis of the various methods of fraud assessment in France (with other national social security funds and other social bodies) and in Europe – especially in the United Kingdom and Germany. » Then it was time for a finer assessment, in the main items of expenditure, based on statistical methods. In order to proceed in stages, the Social Security first looked at the fraud of liberal nurses and complementary health care (ex-CMU). For the last item of expenditure, the body compiled its statistics from 10,700 randomly selected files.
What are the next professional categories screened?
By the end of 2023, work will include daily allowances, medical carriers (ambulances), general practitioners and specialists, physiotherapists, home hospitalizations, and the biology sector (laboratories).
Also read: A Vitale card scam targets victims via SMS
What is a fraud?
For the one with the complementary solidary health, the Health Insurance estimates that it starts when the real resources of the insured are three times higher or the ceiling of the complementary solidary health (without financial participation), set at 9,203 € for one person. alone, and € 19,327 for a couple with two children. Therefore, if a single person who declares more than € 27,609 in l ‘, wants to be reimbursed his care from CPAM in the framework of complementary health solidarity, the behavior will be considered fraudulent and was not attributable to an “error”.
The anti-fraud services of the CPAM are concerned, in particular, by fraudulent, free-up fees of more than EUR 200 000 per year, as reported by the Court of Auditors in 2020. „Necessarily reflect the billing of fictitious or overrated acts or the billing of acts actually performed by several nurses”. The report added that in 2018, 2.1% of nurses, for a total of 1,838, charged more than € 210,000 in fees.
What do the initial assessments reveal?
The amount of financial damage to liberal nurses with misconduct or fraudulent practices is estimated at between € 286 million and € 393 million out of € 7.5 billion reimbursed in 2021 by Health Insurance. The fraud rate is estimated at between 5 and 6.9%.
The other education concerns the insured beneficiaries of the Complementary Health Solidarity with financial participation. It replaced the CMU-c. The fraud rate is between 1.22% and 8.7%. The range of shortfall for Social Security funds is therefore very wide: between 25 million and 175.6 million euros. This date is to be compared with the € 2.47 billion reimbursed to beneficiaries for complementary solidarity health.
Read also : Why billions of euros of social assistance remain in state coffers
How to fight fraud?
First of all through pedagogy. While some violations are voluntary, others are due to a lack of knowledge of the rules. Thus, from September 2021 the Health Insurance deploys “A device to support newly installed nurses via pedagogical actions on the rules of good invoicing of their acts and systematic checks at 4 months (“ al blanc ”) and at 12 months. »
In order to combat complementary health fraud, “A shared and automated system of perceived resources (the Monthly Resource Device – DRM) has been developed with various social protection bodies”indicates the body.
It is impossible to forget to declare certain income. All primary health insurance funds will have access to the system from the beginning of July. The analysis of computer data by sophisticated tools must allow for efficient detection and detection.