The amount of abuse and fraud detected by Health Insurance is growing. The amount of these frauds recorded in Alsace has just been revealed by the CPAM in a report : for 2015, it amounts to 5.2 million euros, an increase of 34% compared to the previous year (this amount was 3.9 million euros in 2014) .
“This increase, which has been constant for several years, is the sign of a intensification of the fight against abuse and fraud by social organizations. The movement is national, and the results are real: throughout France, more than 1.6 billion euros of fraud and wrongful activities have been detected and stopped by Insurance Illness for 10 years underline the heads of the CPAM of Haut-Rhin and Bas-Rhin.
In Alsace, over the past five years, the cumulative amount fraud detected is 17.9 million euros. The sums are also increasingly significant: the amount of fraud detected in 2015 in Alsace corresponds to three times that of 2010.
The main frauds
• Complementary universal health cover (CMUC). The CMUC offers people with modest resources (less than 720 euros per month for a single person, for example) increased access to care with full coverage of health costs. More than 5 million people benefit from it in France, including 100,000 in Alsace. To fight against fraud, the CPAM ensures that the system benefits people whose resources are modest.
• Work stoppages. Almost all of the fraud detected in 2015 concerned cases of people who had an activity during their sick leave, with a view to combining remuneration and daily allowances. In Alsace, 74,000 work stoppages were checked and 25 files were the subject of sanctions or procedures.
• Nursing. In 2015, the anomalies detected (21 files) were mainly over-billing: the prescription was correctly given, so there was no risk for the patient, but the amount billed was higher than the price set for the procedures performed. “These are not cases of flagrant and organized fraud but rather of abusive practices or which are due to ignorance on the part of certain nurses”.
• Care establishments. In 2015, €1,462,000 in invoicing anomalies were recorded in the EHPAD (hospital for dependent elderly people). “These anomalies are not fraud. In most cases, these are residents for whom acts and services are billed to Health Insurance, when they are already understood and covered under the packages paid to establishments”.
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