By
Jean-Christophe Buchot
Published it
See my news
More’1.4 million euros in fraud in 2023, only in Orne! This is the amount which Primary health fund (CPAM) by Orne discovered and stopped in 2023. An amount corresponding to the billions of euros of benefits that the organization in the department has reimbursed.
On Friday, June 14, 2024, CPAM in Orne presented the results of its actions to combat fraud for the year 2023. These actions made it possible to detect record fraud, double that of the previous year.
Two reasons for this, according to Mathieu Frelaut, director of CPAM in Orne: “the increase in fraud”, especially thanks to new IT resources, “and the strengthening of the fight. If the scammers are creative, we know how to adapt. Regardless of the method, we know how to spot them. » Remember that fraud is an intentional act in bad faith intended to obtain an advantage that harms CPAM and thus society.
Protean fraud
Health insurance plays a significant role in national solidarity i regulation of the healthcare system to guarantee quality care at an optimal price. To do this, a policy on management is implemented to prevent errors and punish abuse. The fraud detected in 2023 was particularly varied: Invoicing of fictitious actions, over-invoicing, illegal exercise of a paramedical activity, declaration of false resources, illegal exercise of an activity during a work stoppage, false declaration of obtaining benefits, etc.
THAT fraudsters increase the number of counterfeit devices.
“There are three types of fraudsters: policyholders with false layoffs, healthcare institutions, especially with manipulation of billing data, and healthcare professionals with fictitious actions or exaggerated prescriptions”, presents Mathieu Frelaut.
When asked who the main fraudsters are, he replies: “ 70% of fraud, by volume, comes from healthcare professionals”, but he immediately puts things into perspective: “The reason comes from the fact that with third-party payment, the main actor that the Health Insurance reimburses is a healthcare professional. Quantitatively, it is therefore normal that professionals are overrepresented. However, we must not stigmatize anyone. »
Although in the minority, these fraud tarnishes the overall image of the vast majority policyholders and healthcare professionals who respect the rules. Above all, this erroneous behavior threatens the solidarity of the health system.
THAT Fraudsters are subject to graduated sanctions which can range from financial fines to legal proceedings, including for health professionals a ban from practising.
An anti-fraud brigade
Within Ornaise’s primary fund, all 200 employees are aware of the fight against fraud (LCF), but ” a dedicated team places great emphasis on detecting fraudsters”, comments Mathieu Frelaut. This team of investigators consists of seven experienced individuals, specially trained and equipped with new, more effective tools.
But even more so, CPAM in Orne now cross-references its data with multiple institutional and public stakeholders, such as CAF, URSSAF, MSA, ARS, Pôle emploi, DGFIP, public prosecutors and law enforcement. Cooperation strengthened by the operational committees to combat fraud (CODAF).
In 2023, 69 reports led to sanctions, including 36 from CPAM services and 33 from its partners. After these administrative investigations, the director spoke in 2023: “Eleven reports to the prosecutor, one ordinary procedure, one conventional procedure and one filing of a complaint. »
A national fraud
To illustrate their point, Bruno Libert, chairman of CPAM, gives us an example of fraud committed by a company: “In 2023 we had a case of a ophthalmological health center, located in Le Manswhere policyholders from Orne went, and throughout French territory, which required referral to the prosecutor’s office in Paris. This fraudulent practice is manifested in the invoicing of fictitious actions and failure to comply with the listing and invoicing of actions. The National Health Insurance Fund responded nationally. But it affected the Caisse de l’Orne, worth €280,000, just for our department! So you can imagine the amount on a national level! »
We understand why the Caisse Primaire Assurance Maladie has made the fight against fraud a national issue and has strengthened its control measures at local level.
Damage
The key figures for the fight against fraud in 2023 are impressive. CPAM in Orne thus has checked 71,099 files for a total amount of €25,189,102 in services.
The ascertained losses (amounts improperly paid out before the fraud was detected) amounted to €2,153,826, including €1,469,221 linked to the fraud.
In addition, CPAM avoided €752,484 in potential damage (future payments avoided thanks to the intervention of anti-fraud teams), including €685,598 linked to fraud.
In numbers
Orne CPAM insures 241,360 beneficiaries who represent88% of the department’s population. It collaborates with 1,416 healthcare professionals and 16,182 employers. In 2023,she reimbursed a total of one billion euros in healthcare.
Notice to policyholders
Faced with an increase in attempted fraud by telephone, SMS or e-mail, CPAM reminds thatshe never asks for the communication of personal information nor any login information. It never asks for validation to pay for a refund or a service. It does not require filling in any form to renew Vitale cards: “Do not hesitate to contact us if you have any doubts,” concludes the director of CPAM.
Follow all the news from your favorite cities and media by subscribing to Mon Actu.
