Nurses singled out by Health Insurance for fraud

According to Health Insurance, a number of private nurses are responsible for fraud and the financial damage is high.


Nurses singled out by Health Insurance for fraud / iStock-Christopher Ames

An investigation commissioned by the Court of Auditors

The Court of Auditors has asked Health Insurance to investigate the fraud in the reimbursement of nursing care in town. The goal? “Better understand the financial losses, by type of risk, to better detect and sanction them, but also to strengthen all the actions aimed at preventing fraud. “The Health Insurance investigation concerns “only” 3,624 files (inspected in 2018). Of this total, 1,370 (38%) have various irregularities. The organization relied on these records to measure the extent of fraud nationwide. According to the organization, the financial loss would concern between 5 and 7% of the payments, for an amount between 286 and 393 million euros (general scheme). It should be noted that the budget allocated to reimbursable expenses is 10 billion euros, including 7.5 billion euros for the general scheme. Note: for Health Insurance, a private nurse who reaches €200,000 in fees per year is suspect. However, in 2018, 2.1% of nurses billed more than €210,000 in fees…

Fraud: how do nurses proceed?

But how do nurses cheat? Some increase their mileage allowances, a “cheating” that accounts for 62% of fraud cases and 39% of overall financial damage. Others invoice imaginary services and still others multiply invoices for the same act (22% of cases, 38% of financial damage). Some have opted for non-compliance with the nomenclature of acts and send too high bills to Social Security and there are also cases of prescription fraud. Finally, in rare cases, the profession is practiced illegally.

A suprise ? Not really !

Is Health Insurance surprised by these numbers? Not really. The number of liberal nurses is around 100,000. However, few checks are carried out. How can it fight against this costly phenomenon? By using artificial intelligence for automated data processing. In addition, from now on, any liberal nurse who settles must go through a blank check then, eight months after his installation, he is the subject of a real check. And, since the beginning of the year, a device of monthly resources (DRM) was launched. By the end of next year, other professions will be targeted by Health Insurance: health transporters, general practitioners/specialists, physiotherapist masseurs… It will also be interested in daily allowances, hospitalization at home and to laboratories.

Fraud in complementary health insurance also scrutinized

The liberal nurses are not the only ones to have been the subject of an investigation by the Health Insurance at the request of the Court of Auditors. The solidarity complementary health fraud is also closely watched. The Health Insurance estimates that there is fraud from the moment when the resources of the insured are three times higher than the ceiling (a little more than 9,200 euros for a single person and approximately 19,320 euros for a couple with two children).

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