There is this guy from Périgord who is on sick leave, but who plays the accordion in the EHPADs as a self-employed person. After cross-checking with his bank, the CPAM of Dordogne realized last year that he had collected 11,000 euros salary with this activity. The Périgourdin confronted with this fraud admitted it. He had to reimburse the daily allowances and pay a fine of a little over 1,000 euros.
“When you are on sick leave, you must cease all activity, paid or not“recalls Sandrine Costardoy, head of the fight against health insurance fraud. In her department, which is growing and becoming more specialized every year, they are regularly alerted to employees on sick leave who are involved in sports competitions on weekends.
A Dordogne transporter deregulated last year
While most fraud detected by agents is committed by policyholders, It is the professional ones that cost the most to health insurance. These are medical acts that are billed to health insurance, but which never existed. “It’s a minority of professionals”is keen to point out Delphine Camblane, the director of the CPAM of Dordogne.
Last year, a Dordogne taxi has been deregistered by the CPAM because he had billed for several patient transports, without actually having carried them out. He is also being prosecuted in parallel for these facts.
1 million euros of fraud in 2023, double expected for 2024
The CPAM detected one million euros of fraud last year in Dordogne, i.e. “approximately 1% of expenses covered by health insurance”explains Delphine Camblane, director of the Primary Health Insurance Fund.
The amount of fraud has been increasing since 2021, but it is difficult to say whether there is more and more fraud or whether it is because health insurance is putting the means to detect it. For 2024, this number is expected to double and “reach two million euros”, especially because Health insurance has put a stop to the excesses of certain new hearing aid companies. Some companies bill health insurance for hearing aids without actually delivering them to patients. There have been some Nearly one million euros of fraud in this sector in Dordogne. From now on, all payments for hearing aids are checked before payment.
Charlotte Jousserand
What sanctions?
More than a hundred fraud cases handled by health insurance resulted in sanctions in 2023 in Dordogne. In addition to reimbursement, the CPAM may require the payment of “penalties” of up to 30,000 euros. or up to 300% of the amount of money fraudulently received.
But it can go further with legal proceedings For “forgery and use of forgery” or for “false statement”. A young man who went to get cancer medication with a fake prescription from several pharmacies in Dordogne has been tried. The young man recruited on social networks was sentenced to four months suspended prison sentence and he will have to reimburse the cost of these drugs.
From social networks to the dark web
At the CPAM of Dordogne, there are five people in the department to detect fraud. 70% of fraud cases come from reports from Périgourdins, employers, health professionals. These CPAM investigators also receive reports from their colleagues on the floors below who have detected inconsistencies in the files. This goes further with the work of health insurance statisticians who will note anomalies in the CPAM data.
To verify everything, the five sworn investigators can request verifications and data to public finances, law enforcement, the pension fund, the MSA, highway services and even banks.
The fake “increasingly consistent with the original”
The fraud techniques are “more and more elaborate […] The fake is increasingly consistent with the original”explains Julien Irvoas, accounting and financial director of the CPAM. For example, there are, these sick leave kits, “You can find them on the internet, and you have all the necessary documents to request daily benefits from health insurance”. The CPAM has uncovered this scam, “It was always for management positions, paid 8,000 euros per month, in large companies and with three or four months of sick leave”explains Sandrine Costardoy, head of the fraud unit.
Health insurance is currently training around ten “cyberinvestigators” to form a regional hub in Nouvelle-Aquitaine. They will have judicial police powers. and will be based in La Rochelle (Charente-Maritime). These cyber investigators will be tasked with “identify all new fraud techniques in order to prevent them.”
