2023-10-06 13:00:29
How can we uncover fraud in a system where 1.2 million healthcare professionals and 60 million policyholders intersect, generating 1.4 billion care forms per year? How to thwart ever more inventive fraudsters, for whom each new field opens up to reimbursement – antigenic tests during the Covid-19 crisis, hearing aids since the implementation, in 2019, of the 100% health measure (without remainder dependent)… – is a new area of potential fraud? For Thomas Fatôme, director general of the National Health Insurance Fund (CNAM), the mission of the 1,600 agents (out of 60,000) dedicated to the fight against abuse – who will soon be 300 more –, the mission is “difficult, but not impossible”.
In 2022, they detected 316 million euros in undue payments, which is both a lot and a little if we compare this amount to the 240 billion euros in annual health spending that Health Insurance manages. Health professionals are at the origin of 68% of the damage suffered by the CNAM, compared to only 21% for the insured, a distribution contrary to popular belief, which is explained by the evolution of the health system: with the advent of third-party payment, the latter now pays the former more often than it reimburses the latter, since, with this system which avoids the patient having to advance the costs, it is the “Secu” which directly pays the healthcare professional. health.
This advance has made life easier for citizens, but it has “also significantly increased the risk of fraud”, noted the Court of Auditors in 2020, in a report which pointed out the flaws of Health Insurance in this area, particularly since 2016 and the establishment of a “payment guarantee” to encourage health professionals to switch to third-party payment. At the time, it was a matter of reassuring caregivers who feared being overwhelmed by administrative procedures and having to fight to be paid: if the CNAM did not pay them within seven days, it would pay them late payment compensation. .
Atypical behaviors that alert
With third-party payment, the patient, exempt from fees, no longer monitors the expense. The temptation then exists for the healthcare professional to overbill for procedures or to declare fictitious ones to the CNAM, which, forced to meet its payment deadlines, no longer has the time to sift through the care sheets and prescriptions. and invoices she receives. “Health Insurance largely dismantled existing controls, which were already insufficient, when a guarantee of payment within seven days was granted to professionals practicing third-party paymentnoted the Court of Auditors. The irregularities made possible by the absence of automated controls are very numerous. »
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