Nurses singled out by health insurance for fraud

Nurses singled out by health insurance for fraud

According to health insurance, a number of private nurses are liable for fraud and financial damages are high.

Nurses singled out by health insurance for fraud / iStock-Christopher Ames

Nurses singled out by health insurance for fraud / iStock-Christopher Ames

An investigation commissioned by the State Audit Bureau

The Court of Auditors has asked health insurance to investigate fraud in the reimbursement of nursing care costs in the city. Target? “Better understanding of financial losses, by type of risk, to better detect and punish them, but also to strengthen all actions aimed at preventing fraud.” The “health insurance investigation concerns 3,624 files” only (examined in 2018). Of this total, there are 1 ,370 (38%) have various irregularities. The organization relied on these records to measure the extent of fraud nationwide. According to the organization, the financial damage will relate to between 5 and 7% of payments, in the amount of between 286 and 393 million euros (general scheme It should be noted that the budget for reimbursable expenses is €10 billion of which €7.5 billion is for the general scheme.Note: For health insurance, a private nurse whose fee is €200,000 per year is suspected.However, in 2018, the payment of 2.1% of nurses billed more than 210,000 euros in fees…

Fraud: how do nurses act?

But how do nurses cheat? Some increase their mileage, which is a “cheat” that accounts for 62% of fraud cases and 39% of the total financial damage. Others bill fake services and others double bills for the same act (22% of cases, 38% of financial damage). Some have chosen not to comply with the labels for acts and send very high bills to Social Security and there are also cases of prescription fraud. Finally, in rare cases, the profession is practiced illegally.

Surprise? Not right !

Was the health insurance surprised by these numbers? Not right. The number of liberal nurses is about 100,000. However, few examinations are performed. How can it combat this costly phenomenon? Using artificial intelligence for automated data processing. In addition, from now on, any established liberal nurse must undergo a blank check and, eight months after installation, undergo a real check. Since the beginning of the year, the Monthly Resource Device (DRM) has been launched. By the end of next year, other occupations will be targeted by health insurance: health transporters, general/specialist practitioners, masseur physiotherapists… He will also be interested in per diem, home and laboratory hospitalizations.

Supplemental health insurance fraud was also examined

Liberal nurses are not the only subject of investigation by the health insurance at the request of the Audit Bureau. Solidarity supplement health fraud is also closely monitored. The health insurance estimates that there is fraud from the moment the insured’s resources are three times higher than the ceiling (a little more than 9,200 euros for an individual and about 19,320 euros for a couple with two children).

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