It is the first one. The Health Insurance, which has already canceled health centers in the past, this time will withdraw a whole network of establishments from its national convention. The thirteen health centers of Alianza Visión, located in various cities in the territory, are accused of having set up a vast system of fraud, indicates the National Health Insurance Fund (CNAM) in a press release published this Friday.
At issue, false claims of care that allowed centers to pocket additional reimbursements. In detail, Health Insurance accuses them of “billing fictitious acts” and “repeated non-compliance with the rules of qualification and billing of acts.”
21 million euros in potential damage
Following this deconvention, dental and vision care provided at these centers will no longer be reimbursed for nearly as long.
“L’Assurance Maladie, therefore, will only cover the care provided in these centers on a very low basis, the ‘authority rate’, that is, for example, for an ophthalmology consultation at 30 euros a reimbursement of 1.22 euros “, specifies the CNAM in its press. release.
This non-convention procedure, which will enter into force on August 21, 2023, will be valid for five years.
Health Insurance quantifies “the economic damage at 7.8 million euros in the framework of the complaints filed.” But this amount “could be revalued as a whole for the entire network by almost 21 million euros, according to the elements of the investigation.”
In fact, the criminal actions are still ongoing after the presentation of 27 complaints since June 2021 by the Primary Health Insurance Funds. According to information from Spot revealed on July 9, “seven people were prosecuted on June 22 for organized fraud, money laundering, and the illegal practice of medicine.”
A “strong signal”
With this large-scale disagreement, the health branch of the Secu wants to send a “strong signal” regarding the fight against fraud.
“Health Insurance is determined to stop the fraudulent excesses of certain actors that are detrimental to all”, warns its CEO Thomas Fatôme.
The national body particularly welcomes the usefulness of reform No. 4 of the health center agreement, signed on April 14, 2022. This tool allows the social security branch to initiate an accelerated disagreement procedure in case of discovery of facts fictitious.
The annual report of the Court of Auditors on Social Security, published in May, estimated fraud against health insurance at 4,000 million euros each year, and indicated that up to 80% was due to professionals.
Source: BFM TV
