Ophthalmology – Health insurance attacks – News

Social security has lodged a complaint against 16 ophthalmological centers suspected of playing on the billing of acts to make more money.

The pricing practices of eye centers are in the hot seat. After two series of checks, the first from October 2020 to June 2021, the second from March to October last, Health Insurance has identified enough anomalies to file a complaint against 16 of them, and entrust the file to the prosecution. from Paris. The targeted structures are suspected of fraud, forgery and use of forgery, and false declarations. It all started with one observation: the cost of care in these centers has skyrocketed in a few years. From €52 per consultation in 2015, it rose, on average, to €90 in 2019. A much higher amount than in a classic liberal practice, where the bill is around €60.

Disguised overcharging

The difference not being justified, the Health Insurance peeled the invoicing of the acts and discovered that certain places diverted the rules to their profit. Main fault: acts carried out during the same consultation were recorded on different dates. A seemingly innocuous but illegal maneuver, because it leads to overbilling. In fact, when an appointment includes several examinations of a different nature, the pricing rule for medical acts requires that only the first be billed at full price. The following are 50% cheaper. For example, if the fundus is followed by a check of visual motricity, this can only be priced at €13.12, and not €26.24. By recording them over a series of dates, the centers avoided the discount, and made more money.

In the same spirit (but to a lesser extent), some have made their client pay for the same act several times, even though there was only one consultation. This is a “false review”. More rarely, examinations on the eyes of a single person have been invoiced for all of the beneficiaries registered on the Vitale card. If confirmed by the courts, the damage amounts to 3.6 million euros. At the same time, other ophthalmological centers with dubious pricing practices have been the subject of warnings, pending possible legal action if they do not rectify the situation.

For their part, the dental centers, which have also multiplied in recent years, are not left out. Pinned in the 2020 “Expenses and products” report of the National Health Insurance Fund, they are in its sights: […] A certain number of recently created centers divert the purposes of the regulations (diversion of the status of non-profit associations), in order to settle in territories where the offer of oral care is abundant and to position themselves on [un segment] essentially lucrative, in particular on prosthetic and implantology activities outside the nomenclature, to the detriment of acts of conservatory care and prevention”is it indicated in the document.

Billing Anomalies: How to Spot Them

It is difficult for the insured persons to know whether or not they have been victims of over-billing: ophthalmological centers are used to practicing third-party payment. Why monitor his account, since there is no need to verify that the reimbursement has indeed taken place? The statements are however available on each Ameli personal account (Health Insurance), taking a look at them costs nothing. The main point to observe is the date of care. The examinations carried out during the same consultation cannot be spread over a series of days. If the ones you suffered were counted several times, or extended to your children, that’s not normal either. Report it to your fund. Seeing if the acts declared are those that have been carried out is less easy, because the nomenclature remains difficult to understand. If in doubt, contacting Health Insurance is a good reflex.

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