Health insurance fraud: the 2022 results mark a new record

The first results of the fight against health insurance fraud in 2022 have just been published (they are provisional but official).

Of the €315.8 million in losses detected and stopped last year, almost three-quarters relate to health costs, mainly wrongly billed by health professionals (consultations, procedures, reimbursements for treatment and drugs, etc.). The year 2022 was also marked by scams relating to the delivery of antigenic tests to healthcare professionals by community pharmacies, for an amount of more than €58 million.

Out of €316 million in loss, 57 million (18%) comes from policyholders (daily allowances, disability pensions, universal health protection, complementary health insurance).

Which sectors concerned?

As we told you last October, nurses, pharmacists, suppliers of medical services and equipment and carriers represent a significant part of the damage. The main grievances relate to non-compliance with regulations or nomenclature, fictitious acts or prescription fraud. Health centers also concentrate a significant part of the attention.

Only Big Data can handle such a flow of data

Faced with more and more medical acts and sales, the Health Insurance ensures that it does everything possible to repress and avoid recurrences of fraudsters. Of the 8,817 litigation actions initiated in 2022, nearly two-thirds consist of criminal proceedings and financial penalties for an amount of 16 million euros. Other contentious sanctions include warnings, referrals to professional orders and contractual procedures.

In the midst of all these abuses, only 2 health centers have been revoked…including 1 in ophthalmology…a record all the same since it is a first.

€316 million in fraud on the €230 billion health insurance budget

“The vast majority of policyholders and professionals respect the rules of the game,” says Thomas Fatôme, director general of the national health insurance fund. We now have more than 1,600 agents who specialize in this fight against fraud. We have also invested in information systems to recover the data”.

But as everyone knows, fraud is always one step ahead.