6.5 million euros in fraud identified by Loire-Atlantique Health Insurance, a record figure

6.5 million euros in fraud identified by Loire-Atlantique Health Insurance, a record figure
6.5 million euros in fraud identified by Loire-Atlantique Health Insurance, a record figure

More than 6.5 million euros of fraud were detected or stopped in 2023 by Health Insurance in Loire-Atlantique, a record amount which exceeds the objective of 6.3 million euros that the organization has set itself. was initially set.

“Acceleration of controls, constant strengthening of human and technical resources”the anti-fraud strategy implemented by the Primary Health Insurance Fund has paid off.

468 cases involve healthcare professionals for an amount of more than 5 million euros. 235 policyholders were arrested for fraud valued at more than one and a half million euros.

In total, 703 frauds were stopped and detected, with a record number of 196 litigation outcomes.

More than 6.5 million euros of fraud were thus detected or stopped where the objective was set at 6.3 million euros.

To arrive at this “record” figure, the CPAM deployed “new tools and skills in data processing, in order to more quickly group, cross-reference and identify irregularities likely to reveal cases of fraud”.

Two emblematic cases marked this campaign of reinforced controls and investigations. The first concerns

The first case concerns a pharmacy. Taking advantage of the COVID-19 pandemic, the pharmacy embezzled more than one million euros of public funds.

“The fraudulent practices were numerous: invoicing for masks never distributed, invoicing for contact tracing never carried out, use of unqualified personnel to carry out antigenic tests, non-compliance with regulatory prices, and invoicing for screening without agreement with the laboratory”specifies the CPAM.

Their irresponsible behavior not only caused significant financial damage, but also compromised the fight against the spread of the virus, by diverting essential measures aimed at breaking the chain of transmission of COVID 19

The financial penalties commission imposed a financial penalty of 598,000 euros against these two pharmacists. to which the Council of the Order added practice bans for the two pharmacists involved. The Nantes prosecutor recently took up the case in order to determine the possible application of a criminal sanction.

The second file concerns a regional director, “who has accumulated daily work accident benefits with paid professional activity”. This fraud cost Health Insurance more than 128,000 euros.

The criminal court handed down an exemplary sentence, ordering the full reimbursement of the damage to the CPAM, the confiscation of the sums seized from the bank accounts of the insured of more than 86,000 euros and, a fine of 10,000 € accompanied by a reprieve.

For Health Insurance, as for public authorities, the fight against fraud remains a priority.

“It aims to dissuade actors in the health system (care providers, insured persons, employers) from transgressing the rules and thus contributes to the sustainability of our social protection, in the interest of all. The control themes concern all audiences and the surveys carried out concern both the obtaining of rights and the services presented for reimbursement. Certain operations are part of national programs and are articulated within the regions”underlines the organization.

17 agents were dedicated to this fight against fraud.

Faced with the complexity and constant evolution of forms of fraud, innovation is placed at the heart of the strategy to detect false work stoppages sold via social networks, identity fraud, falsification of authentic documents, trafficking of medicines, RIB fraud

Working in partnership is important. An agreement with the Nantes Interministerial Research Group (GIR) is currently being signed.

The Loire-Atlantique Primary Fund covers more than 1.4 million beneficiaries in the department and paid more than 3.9 billion euros in benefits in 2022.

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