Treatment will no longer be reimbursed at the two health centers accused of fraud

On Sunday 22 January 2023, Health Insurance announced that it would cancel the ophthalmology and dental center in Seine-Saint-Denis and the dental health center in Yvelines for five years, starting 23 January and 1 February 2023 respectively. They will be based in Blanc-Mesnil and the Trappes, according to the paper Parisian.

Determination of fake invoices, fictitious action invoices, meaning that they are not done … “An investigation has been carried out and has confirmed fraudulent practices” came from these two centres, with a total financial loss for the evaluated Health Insurance of almost 1.5 million euros, he explained in a press release.

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What are the consequences of this decision?

Health center deconvention implies that Health Insurance only supports care that is performed on a very low base, authority rates. Or, for example, for a €30 ophthalmology consultation, a €1.22 reimbursement.

Health Insurance “Therefore it strongly advises its policyholders not to use these centers, a fortiori given the fraudulent practices that have been detected there. It reminds that medical centers have an obligation to inform patients about the price and conditions of their treatment and exemption from advance fees..

What are the other centers in his sights?

Yes. 88 dental health centers and 44 eye health centers are currently being examined by the health insurance fund, both newly opened centers and groups.

Control enabled “when significant billing atypicals are identified”and carried out in conjunction with the judiciary and police/gendarmerie services as part of “national task force”determine the National Health Insurance Fund (Cnam).

Why target these centers?

The development of dental and eye health centers has been favored to increase the supply of care. But the National Assembly voted in late November 2022 in favor of a stricter framework for these structures, as some of them are presented as “money machines”.

The number of eye centers receiving more than 500 patients has increased, for example, from 88 in 2015 to 157 in 2020, according to Cnam. However, he recorded in parallel in the visual sector “50% increase in the average cost of care per patient”an increase in expenses by 250% from 20 million euros in 2015 to 69 million euros in 2019 and reports from policyholders or healthcare professionals.

How does Health Insurance fight fraud?

On 30 September 2022, Cnam announced that it wants to double the amount raised from the fight against fraud in two years, reaching 500 million euros in “danger detected and stopped” in 2024. Dan promised to start legal proceedings and deconvene health centers that would not play the game.

26 complaints were subsequently filed against a network of twelve eye health centers (located in Ile-de-France, Provence-Alpes-Côte d’Azur, Normandy, Hauts-de-France, Pays de la Loire, Auvergne Rhône-Alpes, Center -Val -de-Loire and Grand Est), facing expected financial losses “over seven million euros”. Others are ongoing against dental brands or in the hearing field.

Another available way for this is automatic cross-referencing of data with the Ministry of Economy and Home Affairs. That “big machine” has made it possible to target 1.6 million policyholders in one year, and write off 300,000 after verification… “limited financial impact”around 70 million euros.

Finally, Health Insurance intends to better control caregivers, to whom nearly two-thirds (in the number) of fraud detected in 2021 is related, even if they “small minority facts”. After looking at certain liberal nurses charging exorbitant fees, Cnam put his specific estimate at around 200 million per year “endanger” caused by a general practitioner. Ditto for paramedics, taxis and other “medical transporters”.