Health insurance fraud: a record amount of 9.1 million euros recovered in Hérault in 2023

Philippe Trotabas, in the center, Anne Matillo, consulting physician and Noémie Bonnet-Aldigier, deputy health director of the CPAM of Hérault. Midi Free – DORIAN CAYUELA

In 2023, nearly 9.1 M€ Compensation received as part of fraudulent declarations was recovered by the Hérault Primary Health Insurance Fund, behind an offensive strategy on the subject. A record sum attributable, for 76% of its amount to health establishments (26%) and care providers (50%) and 24% to users.

This is a notable increase of 87%: in 2023, the action of the Hérault health insurance services against fraudulent behavior made it possible to recover 9.1 M€ of compensation received unduly. A record amount, compared to the 4.80 M€ resumed in 2023. This phenomenon is also observed on the scale of Occitanie (40.20 million euros recovered) as well as on the national scale. "This is not the result of chance but the result of a national strategy", indicates Philippe Trotabas, the director of the CPAM of Hérault, which also coordinates efforts on the subject across Occitanie.

Audioprosthetists in the crosshairs

These results can be explained, according to the manager, by targeted national campaigns which notably targeted hearing care professionals from mid-2023. Fictitious services, a lack of delivery of materials (reimbursed at 100% since 2021), the absence of certification of professionals or even canvassing attitudes have been observed. In Hérault, these behaviors were at the origin of six criminal complaints and an amount of 200,000 euros. fraud avoided.

Overall, the "providers of care and services"as well as health establishments are at the origin of 76% of the amount of fraud recorded in 2023 compared to 24% for policyholders even if the latter are the most numerous in volume (58% ;% of fraudsters).

Recruited cyber investigators

According to Philippe Trotabas, the increase in CPAM staff dedicated to the fight against fraud, 19 people then 26 since this year, partly explains these results. "This is one of the priorities of Health Insurance because it is a challenge to the solidarity pact. We are coordinating more and more with the police, the gendarmerie, the justice system. We share expertise. The frauds that we discover are the subject of information sharing in all departments, he continues.

Since last year, the funds have also had, in addition to the right of banking communication, the possibility of imposing fines for amounts of up to 300% of the damage. In Hérault, these penalties represented a sum of 400,000 euros, a product multiplied by five. "C& rsquo;is a fast, effective tool" we appreciate at the CPAM of Hérault.

The medical advisors in support

Advising doctors also play an important role in monitoring health professionals and health care establishments. "Our mission is to fight against dangerous practices, excessively high dosages, abuse of care, beyond the needs of patients, for example rehabilitation sessions for months" indicates Anne Matillo, medical advisor to the regional directorate of the health insurance medical service.

The professional also tracks erroneous invoicing for procedures that are not reimbursable, and controls the prices of health establishments. Particular attention is therefore paid to plastic and reconstructive surgery procedures. "If it’s for aesthetic purposes we do not take into account" indicates Anne Matillo whose control is also exercised, with policyholders, on "mega-consumers", risky practices which can also lead to drug trafficking internationally or for drug use. "Pregabalin, Lyrica are quite fashionable at the moment for their opioid effects".

Philippe Trotabas and his teams estimate that fraud in the department still remains above 9 M€. To strengthen these efforts, the State has decided, in 2024, to recruit 60 cyber investigators on these specific subjects. "On false work stoppages, false pay slips we realize that we are faced with organized gangs who sell kits to policyholders on the dark web",  reports to Noémie Bonnet-Aldigier, the fund's deputy health director. Teams have also specialized in the theft of health professional data, making it possible to multiply fraudulent documents. In 2023, in the department, trafficking in false vacation slips for Covid tests carried out in pharmacies was thus identified.

In 2023, the insurance fund initiated no less than 64 criminal proceedings against the perpetrators of fraud.

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