Health Insurance's increased efforts in the fight against fraud in 2023 enabled it to increase fraud detected and stopped by 50%, to 466 million euros.
This increase is “the fruit of the mobilization of Health Insurance on all issues of fraud”, whether it comes from “health professionals, policyholders, companies”, indicated Thomas Fatôme, its general director. , presenting the annual report.
The organization intends to step up its efforts in the years to come: it is targeting 700 million euros of fraud detected and stopped in 2027. Prime Minister Gabriel Attal set a target last week of 2.4 billion in fraud detected and stopped in 2027. stopped over four years by 2027.
The amount of penalties imposed on fraudsters increased by 28% in 2023, to 25 million euros.
60 cyber investigators
Health Insurance has around 1,500 agents responsible for combating fraud, and plans to have 300 more by 2027. In particular, it is in the process of installing teams of cyber-investigators in six interregional centers ( Blois, Grenoble, La Rochelle, Lille, Marseille and Paris).
These cyber investigators - 60 in total - will have judicial police skills to be able to infiltrate groups and networks which exchange tips and false documents online to abuse Health Insurance.
These teams will be operational “from the third quarter of 2024”, according to Marc Scholler, deputy director of audit, finance and the fight against fraud at Cnam.
Fictitious acts, multiple invoicing
By field of activity, health centers (ophthalmology, dental) and hearing aid specialists are particularly scrutinized today. More than 200 health centers were audited by Health Insurance in 2023. Twenty-one were suspended for abuses such as billing for fictitious procedures, multiple billings for the same procedure or unjustified care.
“It is very likely that we will have new deregulations by the summer,” indicated Thomas Fatôme. Fraud detected and avoided in these establishments represented, in 2023, 58.1 million euros, or eight times more than in 2022.
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As for audio prostheses, Health Insurance seeks to identify and stop the scammers and unscrupulous companies who have burst onto the market since the entry into force of 100% Health (generalizing reimbursement for hearing aids). Increased surveillance made it possible to detect 21 million euros of fraud in 2023 in this area, in particular practicing without a hearing aid diploma.
The organization indicated that it had obtained the criminal conviction of managers of a company who “had deployed dozens of sales agents in nursing homes in France by passing them off as hearing aid specialists”.
Fraud rates between 2 and 7%
The total amount of benefits paid by Health Insurance in 2023 was 247.6 billion euros, according to figures from the Social Security financing law passed in December in Parliament.
In-depth sectoral controls show fraud rates “generally” between 2 and 7%, according to Thomas Fatôme. According to estimates already made public by Health Insurance in 2022 and 2023, nurses or physiotherapists have fraud rates (abusive, faulty or fraudulent practices) at the top of the range: 5 to 6.9% for first, 5.2 to 6.8% for the second.