On September 30, Health Insurance presented its global anti-fraud strategy, which is also a central theme of the Social Security Financing Act (PLFSS) for 2023. Its plan of attack includes monitoring after the application of 100% of the health legislation using hearing aid professionals and opticians who will be subject to control.
Over the past 10 years, the total amount of financial damage detected and stopped by the health insurance amounts to 2.2 billion euros (219.3 million euros in 2021). Two-thirds of fraud is committed by healthcare professionals, mainly nurses, pharmacists, medical service and equipment suppliers and transporters. Their actions focus on non-compliance with regulations or nomenclature, prescription fraud and fictitious actions. Last year, Sygesikringen thus initiated 7,857 legal proceedings (4,771 in 2020 and 8,872 in 2019), which gave rise to fines of a total of 34.6 million euros (20 million euros in 2020 and 31.1 million euros in 2019). Its 2021-2022 action plan to combat fraud was based on several pillars. The first consisted in continuing the control in a permanent and periodic manner, especially against the health 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.
Improved care for 100% health justifies control
To eradicate fraud, health insurance relies on prevention, namely prior checks to ensure proper allocation of rights to policyholders and fair payment of benefits. It will proceed with systematic checks that prevent unauthorized offers and the implementation of the digital prescription (currently being tested, generalization is planned for the end of 2024), which will prevent the falsification of prescriptions. In terms of fraud detection, continuous monitoring of new risks will be carried out (especially on social networks) and control will be strengthened with teleconsultations, expensive medicines, but also 100% health, targeted “opticians and hearing prosthetists, for whom the health insurance now covers a much higher cost than before “. However, it appears opticians are more concerned than sound. According to the Health Insurance 2022 Cost and Income report, the latter are actually quite good students of compliance with Class I selling price limitswhich is an important element of the 100% health regulations.
Towards tougher penalties
The purpose of Sygesikring is to systematically punish fraudsters (through criminal proceedings in the case of invoicing fictitious actions, fines in the case of over-invoicing or failure to comply with the nomenclature, and the ordinary procedure in the case of unsafe or unethical practices). It also intends to resort more regularly to the deconvention of health workers 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 organized gang fraud) in cases of fraudulent practices.