Health insurance fraud in Gard: more than €4.8 million detected in 2023, up 72% compared to 2022

Aurore Crouzet, deputy director of CPAM; Alain Chelloul, director and Didier Trouvé, head doctor of the Regional Directorate of the Occitanie Medical Service. Midi Libre – E.Be

Intensification of controls, recruitment of agents, more severe sanctions… Faced with fraud by policyholders, but also professionals, health insurance is deploying a massive plan, which is already bearing fruit.

In 2023, the Gard Primary Health Insurance Fund (CPAM) will have paid 2.7 billion euros in aid. But, faced with potential abuse, the organization strengthens its vigilance, year after year."We have two types of controls to verify that this money is distributed correctly, explains Alain Chelloul, director of the CPAM du Gard. So-called "quality" controls, which allow both the beneficiary's errors and our own errors to be reported. Out of 187,000 files studied in 2023, 29,000 showed undue sums, for a total amount of 10M€." An already very substantial sum. "We also have an anti-fraud strategy which, in 2023, concerned 309 files for 4.8 M€."

Insured fraud on the decline

4.8 M€, a record figure, up 72 % compared to 2022. The result of an acceleration and intensification of controls, which are accompanied by ;rsquo;greater severity in sanctions. But are these fraudsters, among the 711,000 beneficiaries in Gard and 5,600 health professionals?? "The insured represent 56  ;nbsp;% of the number of frauds, compared to 37% from care and service providers and 7% from health establishments, reveals Aurore Crouzet, director assistant. Which, however, pushes the analysis further: if health professionals concern, therefore, "only" 37% of files, they represent 80% of the total amount of fraud detected. Against 15% for policyholders (down compared to 2022) and 5% for health establishments.

Reinforced sanctions, a new offense in 2024

The 2023 and 2024 social security financing laws have strengthened the repressive arsenal, particularly in terms of financial penalties. The amount of which can go up to 300% of the damage suffered: "Let's imagine that the amount of the fraud is 1 000  €. If these 1 000 € have been paid, the fine can be 4,000 euros. Or 3 000 € if they have not yet been paid", illustrates Aurore Crouzet. In 2023, 48 legal proceedings were initiated, including 12 criminal proceedings (+33% compared to 2022) and 11 financial penalty proceedings. In 2024, new provisions will also emerge, including the creation of social fraud offenses, which includes a penalty of three years' imprisonment and 250,000 euros. fine incurred for the supply of "kits" with the aim of obtaining a right, a benefit or an undue payment, but also two years of imprisonment and 30,000 euros; fine for inciting social fraud. The cancellation of the payment of social security contributions will also be applied in the event of a sanction for fraud by a health professional (on the share of income obtained fraudulently).

The types of fraud encountered ? "At the insured, we can be sure of the concealment of resources, the number of people in the home, forgery of documents(false sick leave, false pay slips, false medical prescriptions, etc.) or even identity theft, details Aurore Crouzet. This is why we have implemented a reinforcement of the requested documents." As for health professionals, "we will find fictitious acts, that is to say acts billed but not carried out, of the overbilling for medical procedures or even multiple billing for the same procedure." And things can go very far: "We have already raised a fraud for a single practitioner which amounted to 700 000 €…" , deplores Alain Chelloul.

Audioprosthetists in the crosshairs

In 2023, major national campaigns have been implemented. Among them, hearing aid professionals were targeted. And in the game of who seeks finds… "The in-depth checks made it possible to avoid 196 969 € of fraud in the Gard. " Through an analysis of invoices emanating from this profession accompanied by reinforced controls, the campaign allowed, at the national level, the verification of 160 companies of ’ hearing aid specialists, having "resulting in the deregistration of around ten of them since 2024 and more than 300 criminal complaints filed in 2023 against ;hearing professionals"… And one thing is certain, the fight against fraud will continue to intensify: in 2024, "60 cyber-investigators, with judicial police prerogatives, will join health insurance for infiltration and investigation operations in the digital field.

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