How Health Insurance wants to speed up the fight against fraud

Show that the National Health Insurance Fund (Cnam) is fully mobilized against fraud: this is the clear message sent by its director general, Thomas Fatôme, during a press conference, Friday, September 30. For the senior civil servant, former deputy chief of staff to Prime Minister Edouard Philippe, there is no question of letting it be said that the Health Insurance would not be competent to stem the phenomenon. And this, while a parliamentary report made public in the fall of 2019 had pointed to failures on the side of the administration and caused a lively controversy.

It must be said that the task of health insurance is daunting. The social organization manages 230 billion euros of health expenditure per year. Above all, it must “supervise” an impressive number of different actors – 60 million policyholders, 3 million employers and hundreds of thousands of health professionals – and ensure the correct payment of multiple benefits (health costs, benefits in cash, etc). In fact, it is impossible for the 1,600 agents specifically dedicated to the anti-fraud mission to control everything.

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Nevertheless, since 2012, Health Insurance has managed to recover 2.2 billion euros in financial damage. In 2021, a year still marked by the health crisis, it flushed out 219.3 million euros paid fraudulently. A figure which should be exceeded this year, since “111.7 million euros in financial damage at the end of June, or 20% more than in the first half of 2021”, have been found. “Our objective is to detect 500 million euros per year by 2024”, explained Thomas Fatôme, without going into details.

Surveillance of healthcare professionals

A question logically arises: who are the fraudsters? According to Health Insurance, the results are clear: “Almost two thirds of the fraud detected (…) are concentrated among health professionals. And four professions are particularly in the crosshairs of the authorities: nurses, pharmacists, providers of medical services and equipment, and carriers. Concretely, between 5 and 6.9% of the acts declared by the liberal nurses, for example, would be fraudulent. This represents a financial range of between 286 and 393 million euros per year, according to Cnam. For general practitioners, the fraud would be lower: between 185 and 215 million euros per year. For their part, the carriers – medical carriers and taxis – are not exempt from reproach either. Around 150 million euros would be defrauded each year (fictitious services, multiple billings, non-compliance with regulations, etc.).

Conversely, fraud from policyholders would constitute a financial issue “a priori more limited”, underlines the social organization. This does not prevent the public authorities from intensifying controls, in particular on foreign people who work or reside in France, and who, since 2016 and the establishment of Universal Health Protection (PUMa), “have the right to cover their health costs”. Since the introduction of the measure, 1.6 million individual checks have been carried out each year. Result: between October 2021 and September 2022, 300,000 policyholders saw their rights removed. Of these 300,000 people, 20% had “consumed care for limited amounts” (total less than 70 million euros), estimates the Health Insurance.

No more excess Vitale cards

Another controversial subject: the Carte Vitale. Health Insurance has been accused in recent years – sometimes by parliamentarians – of anarchic management of Vitale cards. And among other things, to leave in circulation too many Vitale cards compared to the actual number of insured. On this point, Thomas Fatôme recalled that “for six years, Health Insurance has cleaned up excess cards”. The social organization confirms that “since 2018, the general scheme (health insurance, editor’s note) is no longer in excess between the number of insured persons managed and the number of activated Vital cards in circulation (…)”. According to Cnam, today there are only 3,400 excess Vitale cards that circulate within the agricultural regime and special regimes.

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After noting a fraud, the Health Insurance does not refrain from using a wide range of sanctions (financial penalties, ordinal and conventional referrals, criminal complaints). For example, in 2021, “8,000 litigation actions were initiated, including 2,300 criminal actions”. This year, the organization notably filed 26 criminal complaints against 12 health centers which had created financial damage of 7 million euros. In 2021, Health Insurance thus recovered 34.6 million euros from legal sanctions (financial penalties, fines and interest).

New tools

To fight against fraud, Health Insurance is banking on the generalization of digital prescriptions planned for 2024, but also on data mining algorithms (artificial intelligence). The idea is, for example, to more easily identify health professionals who abuse teleconsultations (a threshold of 20% of teleconsultations is now authorized) or who deliver too many medical leaves. The objective is also to fight ever more actively against drug resale channels and against unscrupulous health centers regarding regulations. For this, measures, such as the reinforcement of penalties or the attribution of judicial police prerogatives to certain health insurance agents, have been included in Article 41 of the Social Security financing bill, unveiled by the government on September 26. The challenge is clear: “It’s about protecting health insurance, our common good,” concluded Thomas Fatôme, the organization’s director general.

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How Health Insurance wants to speed up the fight against fraud


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