The increased vigilance of Health Insurance vis-à-vis acts of fraud is bearing fruit. In 2022, the organization detected and stopped the equivalent of an amount of 315.8 million euros of fraud in the reimbursement or practice of various medical procedures, both by medical professionals and policyholders .
This amount is up 44% compared to 2021, and surpasses the previous record of 286.8 million euros intercepted in 2019. In 2020, a year marked by the health crisis, the amount of fraud detected was 127, 7 million euros, down sharply, as controls have been reduced. The objective is to reach a total of 500 million euros of fraud stopped per year in 2024.
Mostly professionals
As with previous reports, the vast majority of fraudulent acts detected by Health Insurance are carried out by health professionals. “Nearly three quarters (of the amount) relate to health costs, essentially invoiced wrongly by professionals”, explains the organization in a press release. These may include, in particular, consultations, procedures and reimbursements for care and abusive medication.
In addition, the health crisis played a role in the swelling of the 2022 balance sheet: 58 million euros of the total are linked to scams on the delivery of antigenic tests to doctors by community pharmacies.
Health Insurance also explains that it specifically focused its attention last year on dental and ophthalmological centers “presenting strong atypia”, that is to say those which would have invoiced disproportionate quantities of acts or multiplied patients. and drug reimbursements. These centers have found themselves at the heart of multiple controversies for practices of abusive acts and dubious medical methods.
Penal and financial sanctions
On the policyholder side, the main frauds detected relate to cash benefits (daily allowances and invalidity pensions) for the equivalent of 35.7 million euros, and fraud in obtaining rights such as universal health protection or complementary health insurance, for an amount of 21.1 million euros. A total of 56.8 million euros of the overall amount, or approximately 18%.
For 2022, tracing fraud resulted in 8,817 litigation cases in France. Two thirds are criminal proceedings and financial penalties. For the rest, the Health Insurance is confined to warnings or referrals to medical orders. The social protection organization can apply a specific sanction, that of the practitioner’s deconvention. Two health centers were deconventioned at the end of January, according to Health Insurance.