Health Insurance’s increased anti-fraud efforts in 2023 saw the company increase the number of fraud cases detected and dealt with by 50%, to €466 million.
The increase is “the fruit of health insurance’s mobilization on all fraud issues,” whether it comes from “health care professionals, policyholders, companies,” noted Thomas Fathom, its CEO, presenting the annual report.
The organization intends to intensify its efforts in the coming years: its target is 700 million euros in fraud detected and stopped in 2027. Prime Minister Gabriel Attal last week set a target of 2.4 billion euros from fraud detected and stopped in 2027. four years by 2027.
The amount of fines imposed on fraudsters increased by 28% in 2023, to 25 million euros.
60 cyber investigators
Health Insurance has approximately 1,500 anti-fraud agents and plans to add 300 more agents by 2027. In particular, the company is in the process of creating cyber investigation teams in six interregional centers (Blois, Grenoble, La Rochelle, Lille, Marseille). and Paris).
These cyber investigators – 60 in total – will have forensic policing skills to be able to infiltrate groups and networks that exchange tips and false documents online to abuse health insurance.
These teams will begin operating “from the third quarter of 2024,” according to Mark Scholler, associate director of audit, finance and fraud at Cnam.
Fictitious actions, multiple billing
In terms of activity, today special attention is paid to medical centers (ophthalmological, dental) and hearing care specialists. In 2023, the Health Insurance Service inspected more than 200 health centers. Twenty-one centers were suspended for abuses such as billing for bogus procedures, multiple billing for the same procedure, or unjustified treatment.
“It is very likely that we will have new deregulation by the summer,” said Thomas Fathom. Fraud detected and prevented at these establishments amounted to €58.1 million in 2023, eight times more than in 2022.
When it comes to hearing aids, Health Insurance is committed to identifying and stopping the scammers and unscrupulous companies that have entered the market since the 100% Health Act (which covers reimbursement for hearing aids) came into effect. Strengthened supervision led to the detection of €21 million worth of fraud in this area in 2023, in particular practice without a hearing aid qualification.
The organization indicated that it had secured criminal convictions for company managers who “employed dozens of sales agents in nursing homes in France, posing as hearing aid specialists.”
Fraud rate from 2 to 7%
The total benefits paid by the health insurance system in 2023 amounted to 247.6 billion euros, according to the social security financing law passed by parliament in December.
According to Thomas Fathom, in-depth industry monitoring shows that fraud rates are “typically” between 2 and 7%. According to estimates already published by the Health Insurance Service in 2022 and 2023, the rate of fraud among nurses or physical therapists (abuse, error or fraud) will be the highest: 5 to 6.9% for the former, 5.2 to 6.8 % for the second.
Source: Le Parisien
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