100% health: The health insurance will strengthen its control and sanctions against opticians

On September 30, Health Insurance presented its global anti-fraud strategy, which is one of the main topics of PLFSS 2023. This program targets, among others, optical shops and sound centers, with particular vigilance in the application of 100% health provisions.

Since 2012, 2.2 billion euros in financial losses have been detected and stopped by health insurance, of which 219.3 million euros in 2021. Two-thirds of detected fraud is concentrated among health professionals, especially nurses, pharmacists, suppliers of medical services and equipment and carriers. The main complaints relate to non-compliance with rules or nomenclature, fictitious acts or prescription fraud. Thus, in 2021, 7,857 legal proceedings were initiated, compared to 4,771 in 2020 and 8,872 in 2019. The total sanctions (financial penalties, fines, damages, etc.) amounted to 34.6 million euros for 2021 (20 million euros in 2021 million euros and 3.21 million euros in 2021). euros in 2019).

The 2021-2022 action plan to combat National Health Insurance fraud was divided into different areas: the first consisted of continued control programs on a long-term and periodic basis, in particular against healthcare professionals suspected of fictitious acts. The effort has particularly focused on eye and dental health centres, drug dealing, teleconsultations, as well as ” on optical and hearing aids as part of 100% health “. The other 2 areas were the implementation of programs against new forms of fraud (drug trafficking, selling fake work stoppages on social networks, etc.) and continuous improvement of detection techniques.

Control justified by the part financed by the Health Insurance at 100% health

The health insurance’s overall strategy goes from evaluation to sanctions. It focuses primarily on prevention with prior checks to ensure proper assignment of rights to policyholders and fair payment of benefits. To move forward, it will be a matter of strengthening the systematic control in particular to make impossible offers that are not approved by the rules and/or nomenclature and to prevent falsification of the prescriptions when implementing the numerical prescription in the course of experimentation ( whose generalization is planned for the end of 2024). In terms of detection and control, the priority measures will then be to carry out continuous monitoring of new fraud risks (especially on social networks) and to strengthen control of teleconsultations, expensive medicines, but also 100% health, targeted optometrists and hearing prostheses, for whom the health insurance now covers a much higher cost than before “.

On the way to more rejections and tougher penalties

Finally, in terms of sanctions, the goal is to systematically punish fraudsters (through criminal proceedings in the case of invoicing fictitious actions, financial sanctions in the case of over-invoicing or non-compliance with the nomenclature and the ordinary procedure in cases of dangerous or unethical practices). Health insurance also intends to resort more regularly to the deconventions of health professionals and to increase the level of sanctions: a measure has thus been integrated into the PLFSS 2023 to increase the financial sanctions (up to 300% of the damage suffered or even 400% in the case of gang fraud) in case of fraudulent practices.

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