Thomas Fatôme, however, nuances on franceinfo the importance of these abuses, affirming that “the vast majority of policyholders and professionals respect the rules of the game”.
“They will charge the equivalent of a prosthesis, when a simple scaling has been carried out”, alert Thursday March 9 on franceinfo the director general of the National Health Insurance Fund, Thomas Fatôme. While in 2022, most fraud comes from healthcare professionals, in particular dental and ophthalmological centers, a new record of 315 million euros has been reached. “It is the translation of the mobilization of teams in detection, control and sanctions”believes Thomas Fatôme.
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The Director General of the National Health Insurance Fund puts this record into perspective, however, if we compare it to the “230 billion euros budget” of the health system. These 315 million euros of fraud “remain a limited sum” And “the vast majority of policyholders and professionals respect the rules of the game.”
franceinfo: How do you explain this record fraud, especially in dental and ophthalmological centers?
Thomas Fatome: This is indeed a record figure, and it is the result of the mobilization of the teams in detection, controls and sanctions. We have in front of us, unfortunately, a certain number of dental or ophthalmological centers which do not respect the rules of what is called the nomenclature of acts. They will quote the equivalent of a prosthesis, whereas it is a simple scaling that has been done.
“Unfortunately, we have a fairly diverse range of fraud in a number of ophthalmological and dental centers.”
Thomas Fatôme, Director General of the National Health Insurance Fundon franceinfo
We currently have about fifty dental centers and more than thirty ophthalmological centers which are subject to control. Our investigators are going to look at each of the files, to see precisely what is happening. Also, during the health crisis, a certain number of actors, in particular pharmacists, went far in fraud during the period of the fight against Covid. This damage is estimated at nearly 60 million euros. More than sixty pharmacies have been sued. We can salute the strong mobilization of doctors and pharmacists on tests and vaccination during the health crisis, but unfortunately, a certain number of them made false invoices to Health Insurance.
When there is an abuse of a center, can the patient realize it?
First of all, these abuses are detected by the work based on data from Health Insurance, thanks to the analysis of our teams. We are doing important big data work to identify the places to be controlled. In a certain number of cases, it is also patients who tell us that the treatment records do not correspond with what they received.
“We invite patients not to hesitate to contact us if they see strange things. Some contact us via the Caisse’s telephone number, 36 46, or by email.”
Thomas Fatôme, Director General of the National Health Insurance Fundon franceinfo
In response, we have just canceled, for example, two health centers in Ile-de-France, other procedures are underway in certain departments. There could be more. By disconcerting, we stop refunds and expenses as quickly as possible when we have proven fraud. Of the 9,000 procedures in 2022, roughly a third will go through the criminal route. We do not hesitate to mobilize this way. We can also mobilize financial penalties. We can also seize the professional orders when it reveals their responsibility.
Do these 315 million euros of fraud have an impact on the Health Insurance budget?
If we link these 315 million euros detected with the more than 230 billion euros of the Health Insurance budget, it remains a limited sum. The vast majority of policyholders and professionals respect the rules of the game. Today we have more than 1,600 agents who specialize in this fight against fraud. We have also invested in information systems to retrieve the data.