L’Assurance Maladie has a well-established fraud control system that often requires cross-referencing of legal and medical expertise. Database analytics, field investigations, various sources… Here’s how to organize the hunt for scammers.
Obviously, nothing escapes the watchful eye of the Health Insurance, which today accuses thirty-four pharmacies of embezzling 53 million euros via false screening tests against Covid-19. It must be said that the fight against fraud is a “priority line of action” for the WHO, and in no way limited to pharmacies. Physicians, physiotherapists, and many other health professionals are carefully monitored with “constantly evolving” anti-fraud technologies and devices.
In 2018 alone, approximately €261.2 million in damages could have been discovered. Interdepartmental data exchange, use of statistical databases through data collection, use of big data… L’Assurance Maladie has a comprehensive and sophisticated anti-fraud arsenal.
Disclosure, investigations and penalties
Health insurance does not allow anything to pass, whether it is due to fraud, but also due to error or misuse. The organization can therefore rely on its extensive databases to “identify potential fraudulent situations, and then conduct a full investigation in order to determine the amount of damage caused to CPAM and the intentional nature of the situation,” asserts a report. of health insurance. Therefore, the purpose of databases is to highlight anomalies and target a specific professional or institution.
However, analysis across the database is only relevant to the first part of a three-step investigation process: detection, investigations, and sanctions. The second part, the investigation, is done on files of documents and supporting documents (and sometimes database studies). As well as in the field, “through teams that include sworn investigators, practicing consultants, attorneys, or statisticians,” Health Insurance Reports notes in its 2018 anti-fraud and control measures. The third part is about penalties that can range from a simple reminder of the regulations to filing a complaint with criminal courts or professional orders, in more serious cases.
Local and collective actions
The control program can also be expanded through partnerships with other players in the public service and social protection organizations (Taxes, Caf, Urssaf, Pôle emploi, Carsat, MSA, etc.) in order to function optimally. Therefore, teamwork can be divided at the local level, for example, through the analysis of bills for medical equipment, nursing care, classification of physiotherapists and massage therapists, and skewed consumption of drugs.
Note that in addition to partnerships, health insurance is also informed by suspected fraud reports from internal services. In 2019, CPAM’s specialized service was to operate 268 still, according to a report from Health Insurance. These reports can result in higher healthcare consumption for insured people, wrong prescriptions or even higher volumes of average medical procedures or fees for healthcare professionals in the same category.