2023-10-05 10:30:05
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Health Insurance is particularly critical of the practices of certain physiotherapists, dentists, specialist doctors and the abuses of hearing aid companies who are riding the growth in this market created by 100% health.
Heavier sanctions, increased controls, cyber investigators, task force to dismantle networks, awareness campaigns… Social Security does not skimp on the means to track down fraudsters. While progressing, the results of the fight against fraud remain modest. In the field of health, Health Insurance detected and stopped 146.6 million frauds in the first quarter of 2023 (+30% compared to the first half of 2022). An amount which should increase to 380 million over the whole year (compared to 316 million in 2022), then 500 million in 2024. A figure “unrivaled» welcomes Health Insurance, but which nevertheless remains timid, not to say disappointing, in view of the billions of fraud mentioned by the financial magistrate Charles Prats and various parliamentary reports.
Read alsoThe Court of Auditors urges the Social Security to better track fraud
Billing for fictitious care by healthcare professionals, false declarations of resources by policyholders, drug trafficking via false prescriptions on the internet, sale of false sick leave on social networks… the list of possible scams is however long. Faced with these multiple forms of fraud, Health Insurance particularly targets health professionals. Responsible for 18% of the volume of fraud compared to 56% for policyholders, there are certainly fewer of them “cheating” the system. But their misdeeds cost Social Security more. In value terms, professionals represent 68% of the amounts defrauded compared to 21% for policyholders.
Read alsoHealth Insurance is prosecuting 12 ophthalmic centers for social fraud
Among the professions controlled in recent months, physiotherapists are responsible for an amount of fraud estimated between 166 and 234 million euros, dentists between 60 and 96 million euros, and the same amount for specialist doctors. In question, most often non-compliance with the nomenclature or regulations and fictitious services constitute the main frauds: overbilling for a procedure by resorting to a higher quote, non-compliance with the duration of a session , invoicing of non-refundable acts…
Also in the sights of Health Insurance, hearing aid companies which are riding the dynamics of this market created by “100% health”. This reform, implemented by the government from 2021, made it possible to be better reimbursed by Social Security and led to a clear increase in the number of patients benefiting from a hearing aid: 790,000 people will be fitted with hearing aids in 2022 (+77% compared to 2019). But hearing aid companies have taken advantage of this: illegal exercise of the hearing aid profession, lack of mandatory monitoring of the beneficiary hearing aids, billing for equipment different from that delivered, convenience orders or establishment of false prescriptions, etc. The damage to Social Security is estimated at several tens of millions of euros. And a large case of audio prosthesis fraud was detected in particular in Seine Saint Denis, for a very high amount of 8.3 million euros.
Policyholders called to make reports
To better combat fraud, Social Security will equip itself with new IT tools: in 2024, policyholders will be able to report fictitious acts or overbilling for care via their ameli account. To fight against trafficking of all kinds which is developing on the internet and social networks, Health Insurance will also be equipped with 60 cyber-investigating agents who will be operational at the end of the first half of 2024.
Because if Health Insurance does education, it no longer hesitates to pull out the stick and crack down on fraudsters. A liberal healthcare professional (doctor, dental surgeon, nurse, masseur-physiotherapist, etc.) for whom fictitious acts have been revealed for a significant amount may thus be subject to both a deconvention procedure, an ordinal complaint and a criminal complaint. And the sanctions have been toughened: increase in the maximum amount of the financial penalty to 300% of the damage suffered, increase of 10% of the amount unduly paid for management fees, etc.
During the first 6 months of the year, more than 3,700 legal proceedings were initiated (+15%), including more than 1,600 criminal proceedings. Last year, the number of litigation proceedings increased by 11% with 8,817 proceedings initiated, mainly resulting in financial penalties (2,648), criminal complaints and Article 40 reports (2,944) and warnings (3,020). As a result, in 2022, financial penalties doubled with 16 million euros in sanctions imposed, compared to 8 million euros in 2021.
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