Ophthalmic centers suspected of health insurance fraud

" Operating anomalies " and " abuses " akin to fraud have been observed in ophthalmological health centers, establishments born of a legislative relaxation of 2018, concordant sources said on Monday, confirming information from the Parisian .

To read also: "Ségur de la santé: open floodgates but no structural reform"

According to the National Professional College of Ophthalmology (CNPO), the new name of the French Academy of Ophthalmology, these " unjustified acts " and these " highly criticizable billing strategies " have been noted by " different sources " in recent months.

Reinforced controls

" Checks have been initiated by the National Health Insurance Fund, which has also identified these deviations, while we are witnessing a rapid multiplication of the number of these centers, " assured the CNPO in a press release.

According to Le Parisien, who had access to an internal report from Health Insurance (Cnam), it is the surge in reimbursements claimed by these new type of health centers, in full swing since 2018, which would have caused arouse suspicion. " For a patient base passed from 400,000 people in 2015 to 800,000 in 2019 (+ 100%), the cost of reimbursements soared by 245% ", to reach " 69 million euros ", underlines this report, quoted by the daily.

Questioned, the Health insurance did not follow Monday the requests of AFP. According to the National Syndicate of Ophthalmologists of France (Snof), several " abusive practices " are behind this increase, such as " billing for multiple orthoptic and medical procedures " and " complex systematized examinations that seem irrelevant ".

" Tariff drift "

" These results highlight a latent phenomenon hitherto ignored by payers, namely a significant price drift (...) detrimental to the whole specialty ", insists in a press release the Snof, hostile to the development of these ophthalmic health centers. The health centers, whose development is favored by the importance of the delays in obtaining an appointment with a liberal ophthalmologist, are contracted in sector 1, therefore prohibited from exceeding fees. They are sometimes accessible in less than 24 hours.

To read also: The "Ségur de la santé" is struggling to agree on salary enhancement measures

In its press release, the CNPO for its part warns against any " amalgam ", in particular " with historic health centers, non-profit, designed on a mutualist model and traditionally managed by local authorities and institutions ". " The ophthalmological medical community calls for vigilance, and counts on the ethics and deontological sense of each of the specialists, " insists the Council.