In 2015, Health Insurance detected and stopped fraud amounting to 231 million euros, an increase of 18% compared to 2014.
“There is no magic formula to lower our health costs,” recently told Why actor Benoît Hamon, candidate for the Primary of the Left (January 22 and 29, 2017). Instead of placing the burden on the sick, the candidate proposes to first fight against contribution fraud. A measure in vogue in the political debates of the 2017 Presidential election. And the following figures will give a little grain to grind to the various challengers.
During the year 2015, the Health Insurance detected and stopped fraud and wrongful activities for an amount of 231.5 million euros, an increase of 18% compared to 2014 (196.2 M € ). This development is in line with the strong growth observed since 2006 (+ 9% on annual average). Result, in five years, fraudulent practices in the health branch have increased by 46%, according to the latest recently published annual report of the National Delegation for the Fight against Fraud (DNLF). According to the DNLF, these figures illustrate “the investment of health insurance organizations in the fight against fraud”.
In more detail, we learn that two thirds (in number) of fraud in benefits (in cash) correspond to administrative fraud linked to work stoppages (daily allowances). The total amount of damage is estimated at € 12.4 million in 2015. The main complaints are: either falsification of work stoppage notices (modification of dates due to overload), or the exercise of unpaid paid activity. allowed during the work stoppage.
Another reason for fraud concerns CMU C, complementary health assistance. This results in false statements of resources, falsifications and false uses.
Work stoppages in the viewfinder
On the responsible side, the DNLF noted a clear decrease in the amount of the total loss for fraud committed by policyholders (0.42 M €, against 0.73 M € in 2014). In percentage terms, the perpetrators of fraud are in less than 8% of the cases insured. Those committed by health professionals (42%) and establishments (50.24%) represent more than 92% of the total amount of fraud detected in the health sector.
And concerning these professionals precisely, the largest contingent of fraudsters are found among nurses (55%), suppliers (23%), pharmacists (7%), physiotherapists (5%) and health carriers (4%). Medical specialists, taxis, dental surgeons, opticians, laboratories and general practitioners each represent 1 to 2% of fraud cases. “This breakdown is broadly similar to the data for 2014”, specifies the Delegation.
Finally, the latter notes that in 2015 fraud gave rise to 50 complaints: 33 against healthcare professionals and 17 against insured persons. A certain number of actions (i.e. 120) were carried out within the framework of the financial penalties system which led to the pronouncement of 84 penalties for an amount of € 57,493 against policyholders, 22 penalties for an amount of 69 € 411 against health professionals.
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