Health Insurance fraud: €9.4 million in damages detected in Haute-Garonne last year

Health Insurance fraud: €9.4 million in damages detected in Haute-Garonne last year
Health Insurance fraud: €9.4 million in damages detected in Haute-Garonne last year
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In 2023, in Haute-Garonne, fraud emanating from pharmacists remains significant in terms of amounts, but in decline however, given the decrease in business linked to the management of Covid (©Pixabay).

Last March, the National Health Insurance Fund (CNAM) revealed the results of its action to combat fraud. €466 million in financial damage were thus detected last year in France, an amount increasing by almost 50% over one year, obtained thanks to the strengthening of its material and human resources and theacceleration of controls.

The results of this more muscular anti-fraud strategy are even more spectacular in the regions. In Occitaniain 2023, €40.24 million frauds were detected, i.e. 98% more than a year ago. In Haute-Garonne, where the Primary Health Insurance Fund has just presented the results of its anti-fraud action, these are €9.4 million in damages who were identified and arrested. A historic amount since it increases by €4 million compared to 2022, i.e. an 87% increase over 12 months.

More human and material resources

The CNAM has in fact strengthened its material and human resources, resulting in a greater number of controls carried out. On the national territory, 1,500 agents are today dedicated to the fight against fraud and 300 additional agents will be assigned to these missions by 2027. At the same time, given the growing complexity of forms of fraud, the National Fund will also recruit and train this year 60 cyber investigators to carry out infiltration operations on social networks and the dark web.

The CNAM has also toughened its attitude towards fraudsters, whether insuredof the health professionals or health establishments. In 2023, a greater number of prosecutions have been initiated (+20%), including nearly 4,000 criminal proceedings (+34%). 3,500 financial penalties were at the same time pronounced (+28%) for a total amount of €25 million (+47%). The social security financing law for 2023 has, moreover, toughened the repressive arsenal since financial penalties can now reach up to three times the amount of the fraud. In Haute-Garonne, the CPAM has initiated 90 criminal proceedings (+104%) and 36 procedures for financial penalties.

Nurses and pharmacists singled out

In the department, the health professionals, who represent 15% of fraudsters, are responsible for the most costly losses: they contribute to nearly 53% of the total amount of fraud detected (€4.9 million). Among these health professionals, nurses and the pharmacists are particularly singled out. They are respectively responsible for nearly €1.6 million and €1.2 million in fraud in Haute-Garonne.

THE hearing aid specialists were also targeted last year by these controls which made it possible to identify €184,000 worth of fraud and led to the deregulation of a store in the department. On a national scale, checks carried out among hearing care professionals made it possible to calculate €21.3 million the financial damage leading to the filing of 300 criminal complaints, including seven in Haute-Garonne.

THE health centers, whose number has increased significantly in recent years, are also in the sights of Health Insurance. Created to develop the provision of primary care in the region, these centers number around sixty in the department and 2,500 in France. Their multiplication was accompanied byan increase in drift : billings for fictitious procedures, multiple billings for the same procedure or even unjustified care. Targeted control campaigns made it possible to detect €58.1 million worth of fraud throughout the national territory. Following these checks, throughout France, 31 centers were deregulated.

Multiplication of false work stoppages

For their part, the insuredwho constitute 68% of fraudsters, represent 40% of the amount of damage, i.e. €3.7 million last year in Haute-Garonne. Among the most common frauds, we can cite: fharsh on rights to Health Insurance (obtaining rights to Supplementary Solidarity Health, identity fraud); THE benefit fraud in kind (falsification of prescriptions and prescriptions); or even cash benefit fraud (pensions, daily allowances, disability pensions, etc.).

Also in the crosshairs of the CNAM, the daily allowance fraud (false notices of work stoppages or transmission of false pay slips, falsification of prescribed work stoppages, exercise of an unauthorized paid activity during the stoppage, etc.) are subject to an special vigilance.

To prevent these frauds which represent in France €17 million including €7.7 million for false work stoppages, Health Insurance particularly wants to encourage practitioners to use electronic work stoppage safer than the paper version. New Cerfas will also be released by the end of the year. Finally, while the social security financing law for 2024 provides that work stoppage prescriptions by teleconsultation can no longer exceed three days or be renewed (unless they are carried out by the attending physician), the CNAM wants to of the fight against trafficking in false work stoppagesone of the priorities of its future cyber investigators. They will be distributed among six inter-regional centers: Blois, Grenoble, La Rochelle, Lille, Marseille and Paris.

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