Medicare is finally beginning to estimate the extent of social fraud.
A figure hitherto very difficult to obtain: the magistrate Charles Prats set fire to the powder by evaluating it at some 30 billion euros and accusing the government of laxity.
The administrations (Pôle emploi, Urssaf, CAF, Health insurance) deny and consider the estimate unrealistic.
Mandated by the executive to shed light on the case, the Court of Auditors failed to decide.
Faced with the pressure of a subject that has become very political, Medicare has embarked on an assessment of fraud in its field, that of health.
With unexpected revelations.
On the vital card, a recurring object of controversy,
“there are no excess cards in the general scheme”,
hammered Friday Thomas Fatôme, director general of Health Insurance.
“There are 3,250 excess cards but none for the general scheme”
.
In addition, nearly two-thirds of the fraud detected is concentrated among healthcare professionals… and not among policyholders.
Each time, the abuses concern fictitious acts, non-respect of the nomenclature, etc.
They are found in particular in three categories: nurses, pharmacists, suppliers.
Tracking down the costing of fraud is by definition complex.
Medicare has therefore decided to proceed “brick by brick”.
The first results, delivered in May, had quantified the abuse of liberal nurses between 286 and 393 million euros out of 7.5 billion euros of care reimbursed by Social Security, i.e. a rate of financial damage estimated between 5% and 6 .9%.
This Friday, Health Insurance evaluated this time the fraud carried out by general practitioners: it would reach between 185 and 215 million euros out of 6 billion euros reimbursed, or between 3.1% and 3.5%.
Another profession targeted: carriers (whether medical vehicles or taxis): abuses reach between 145 and 177 million euros out of 3.6 billion euros reimbursed, i.e. a rate between 3.9% and 4.9%.
Each time it comes to fictitious benefits it
that is to say acts invoiced when they did not take place, or unjustified over-invoicing (for example night rate when this is not the case).
The results for the other professions will follow in the months to come.
Strengthen controls
To better fight against fraud, Health Insurance is focusing on prevention.
Thus, for nurses who move into a new practice, the administration offers a blank check after four months, followed by a real check after 12 months.
An action which aims to strengthen systematic individual support, and should be extended in 2023 to other professions such as physiotherapists for example.
Health insurance is also seeking to strengthen its control and detection capabilities by deploying an analysis and data visualization tool by the end of the year to highlight drug trafficking between healthcare professionals and insured persons and to identify any collusion between doctors, pharmacists and insured persons.
On work stoppages, which have been very
"shaken up by the Covid",
Health Insurance wants to strengthen surveillance, in particular on iterative stops, back problems or depressive syndromes because "
there are too many stops unjustified on these two aspects”.
Finally, on expensive drug fraud, Health Insurance has signed with pharmacists a systematic control for all drugs costing more than 300 euros.
In addition, while Valérie Pécresse, president of the Ile de France region, spoke this week of 500 fraudulent work stoppages at the RATP with 130 layoffs, Thomas Fatôme assures that
"the investigation is in progress, it
is on our radar, we are conducting an investigation targeting health professionals”
.
To better fight against fraud, Social Security is stepping up legal actions: 7,857 legal actions were initiated in 2021, including 2,341 criminal complaints and reports to the prosecutor, and 2,203 financial penalties were pronounced by the administration.
It also intends to deconvention professionals identified as fraudsters, which means that their patients would no longer be reimbursed.
The objective of Health Insurance is to detect 500 million euros of fraud in 2024.
