Financial penalties, criminal convictions, ban on practice, health insurance promises a strong hunt for fraud.
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Antibiotics are not automatic, but the security checks are… “Be careful, speed cameras! This is the message that Medicare wants to send by communicating the results of its fight against abuse and fraud. “Some doctors are being flashed with prescriptions for daily allowances (DA) that greatly exceed the national average, which is 2,200 IJ per year,” says Dr Pierre Fender, the director of litigation control and the repression of fraud in the ‘Health Insurance. He evokes the case of a general practitioner in the south of France who prescribed more than 15,000. The CPAM of his department placed him “under prior agreement”. It was impossible for him to prescribe a sick leave to a patient without having the approval of the medical adviser for 6 months. For this reason, 140 doctors found themselves in this situation in 2008. The controls do not only concern unjustified work stoppages: abuse of 100% reimbursements, misuse of opiate substitutes, abusive prescriptions for medical transport, the National Fund is scrutinizing everything. And especially at the mill of his computers. Is it effective? In 2006, the National Health Insurance Fund (CNAM) achieved 90 million direct savings. In 2008, these savings reached 131 million euros. ” In total, since the launch of the national program in 2005, 358 million euros have been saved, announces Frédéric Van Roekeghem, director of Cnam. Either the equivalent of acquiring 260 MRIs or taking care of 210,000 insured for one year … Obviously, these amounts do not only concern checks with doctors. “This concerns all of our actions with policyholders, hospitals, employers, we want to affect the entire system,” says the director of the CNAM. In 2008, a specific control program was launched on establishments housing dependent elderly people (EHPAD). The majority of nursing homes have been inspected. At the end of 2008, 15.4 million euros of infringements had been detected and stopped. This year, home hospitalization and medical equipment suppliers will be in the crosshairs. Whatever the target, Medicare promises to go all the way. In 2008, the actions taken by the funds resulted in 230 criminal convictions. Since 2005, the number of days in prison has multiplied by 3! Financial sentences totaled 2.3 million euros last year. The actions taken also lead to prohibitions to practice for health professionals. A doctor was banned from practicing for 3 years following a combination of billing fraud and fee overruns. In 2008, the ordinal authorities issued nearly 300 bans against health professionals, following complaints from the funds. It should be noted that the legislator has strengthened the financial penalties system for 2009. The ceilings are increased to 200% of the sums unduly presented for reimbursement. For organized gang fraud, the ceiling is raised to 300%. “Our goal is to dissuade and promote respect for the rules,” says Frédérick van Roeckeghem. The control of the bi-zone scheduler, initiated in 2006, is an example. “The expenses due for this type of fault have significantly decreased. They reached 20 million euros in 2006, they rose to 1.3 million in 2008 ”, according to the director of Cnam. Strong deterrence is not always well appreciated, especially when it is based on statistical thresholds.
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