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Ophthalmology centers suspected of social security fraud


The concept is attractive: a meeting within 24 hours, no excess fees and nothing to pay for patients ... These centers

Faced with the shortage of ophthalmologist doctors, health centers dedicated to sight are starting to grow like mushrooms. Still few in number, they are already in the sights of the National Health Insurance Fund (Cnam), and unions of liberal ophthalmologists. Some suspected practices are reminiscent of the scandal, in 2016, of low-cost dental centers Dentexia which billed for fictitious acts. The entire sector is in turmoil, worried that practices circumscribed to a new model of establishments, non-profit, but where money is flowing, will fall on an entire profession.

What has put the Cnam in the ear is the surge in reimbursements. "For a patient base of 400,000 people in 2015 to 800,000 in 2019 (+ 100%), the cost of reimbursements soared by 245% to 69 million euros (+ 245%)", notes a report internal.

The success is such that historic centers, such as Point Vision, clink glasses: “We have lost 20% of turnover in Paris. We cannot align ourselves with the practices of these centers, some of which are poaching our employees at a high price, ”says Professor François Pelen, president of Point Vision.

Accessible within 24 hours and for some 7 days a week

Prohibited from exceeding fees (sector 1), these new centers - sometimes associated with dental centers - necessarily non-profit are often accessible within 24 hours, for some 7 days a week, when the average time for an appointment in a liberal ophthalmologist exceeds 60 days.

And, a big advantage, they practice full third-party payment, leaving most of the patient base without any leftovers. Patients who, as a result, ignore what has been billed in their name to Health Insurance and complementary health.

In these centers, the patient often leaves with nothing to pay./LP/Jean-Baptiste Quentin  

According to a check of the invoices from the 110 centers which receive more than 500 patients per year, of which we were aware, between 2015 and 2019 the average cost of a visit soared by 63% in these centers, against 11% in liberal cabinet. By concentrating control on the new players, who arrived from 2017, the average cost of 57.50 euros in 2016 reached… 175 euros in 2017, to stabilize at 130 euros last year… + 126% in three years!

"The average amount of a visit to a liberal cabinet was 58 euros in 2019," said Thierry Bour, president of the national union of ophthalmologists in France, who is leading the sling against the new centers. During our testing in a Paris center, the prescription for a simple renewal of glasses cost 92.41 euros. Fully supported. Contacted, Ophthalmology Express, the brand in question (4 centers since 2017), did not follow up. Alliance Vision, born in 2018 and which will soon have 9 centers, is astonished by the figures for Health Insurance, through the voice of one of its associate leaders, Avner Taïeb: “It is good that Health Insurance is doing the cleaning, they come, we are clean. The Liberals do not like us because we are taking customers from them. We go where people need us. "

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The manager does not provide an answer, however, when asked why his group has just created an eponymous "fund management" company, located at the same address, on the Champs-Elysées (Paris VIII).

Billing of unnecessary, even fictitious acts

Many of these new actors have a high standard of living. Ophthalmologists are paid up to 1,500 euros net… per day, three times the average gain in a private practice! The price to pay in times of shortage to attract these essential doctors and qualified to prescribe. On the Indeed announcements site, orthoptists are recruited at 3000 euros net monthly and more. The machines, all new, cost up to 100,000 euros each…

But why so much spending? In reality, the Cnam suspects the organization of a juicy billing of useless or even fictitious acts. Among the 110 centers checked, the report reveals that "around fifteen invoice acts over several consecutive days to more than 10% of their patients, including five establishments for which this practice concerns more than 75% of their patients". In comparison, a liberal cabinet receives again very quickly only 0.5% of its patient base. Why then do the centers bring patients back so often?

The president of the French Ophthalmological Society, Professor Laurent Kodjikian, wishes to warn: “Doctors are responsible for the rating of their actions! It is out of the question for us to endorse such practices. But these centers promising to relieve doctors of administrative tasks, it is a secretariat which rates the acts and sends the invoices. And since the patients see nothing passing, control is difficult. According to our information, a professional union therefore mandated a bailiff who could see that an ophthalmologist with whom an appointment had been made on Doctolib in a given center was consulting, in fact, the D-day at his office located at 1000 km …

Easier health center openings

Everything seems to start from an order from the Ministry of Health dated January 2018. To promote access to care, this text has relaxed the conditions for opening health centers: no need for prior authorization, managers no longer have more than a "compliance commitment obligation". Since then, the centers have grown visibly; they will be more than 120 at the end of 2020, riding the wave of the aging of the population and the difficulties of finding an appointment.

According to the checks made on the Infogreffe website of the companies register, several new brands are managed by companies unrelated to health, which is legally possible: rental of real estate for Care Invest (Ophthalmology express), fund management ( Alliance vision), management consulting for others…

To "get" the money out of this fraud, several techniques are used, often simultaneously. According to various sources, this ranges from premises rented at the price of gold to a “friendly” company, the same goes for control devices, up to the billing of pseudo-advice in gold… In appearance, everything is clean, we don't sees nothing but fire.

"The analysis of the pricing practices of these centers raises questions," slips into its draft budget 2021 the Cnam, which announces an in-depth investigation.

Source: leparis

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