While part of Health Insurance fraud comes from external actors (paramedics, suppliers, patients), another part comes from internal fraud, within hospitals themselves. Moreover, in 2024, Health Insurance noted that 27% of fraud is committed by health professionals, for 68% of the amounts. How do these internal document frauds occur? Who are the actors involved? What are the consequences on the functioning of health institutions and how can we protect ourselves from them? We take stock in this article.
Didn't you read our article on external fraud? Do not hesitate to take a look at it: external document fraud in companies
Administrative services play a key role in admissions management, of repayments And hospital purchases. Unfortunately, some employees use their location to falsify documents and embezzle funds.
Common practices include:
For example, in Beauvais, a medical secretary working for Two liberal doctors a embezzled around 70,000€ over several years. How? It changed the terms of payment on the account books: some patients paid in cash, but it made them appear as beneficiaries of the CMU or Social Security. The payments were then paid for by herself, to the detriment of the doctors.
Discovered during an accounting audit in 2015, she was convicted of breach of trust and received a suspended sentence and the return of the embezzled sum.
Doctors, nurses and other caregivers have access to patient records and medical prescriptions. Sometimes some take advantage of this power to generate falsified documents. In particular, we find:
To help you better understand the extent of this fraud, let's take a concrete example. One French nurse, Maryse Mercier, was convicted for using vital insurance cards and sent falsified prescriptions. She was then reimbursed for fictional acts that had not been carried out. In total? Over 1.5 million euros invoiced!
Hospitals operate with tight budgets.
Each internal fraud leads to direct losses. This money could in particular be invested in the purchase of medical equipment, the improvement of infrastructures, the recruitment of personnel or even the increase of salaries, which are sometimes fragile.
When a hospital is deprived of financial resources, due to fraud, this directly impacts patients.
Equipment is becoming obsolete, processing times are much longer and the available staff is getting smaller.
The discovery of a case of document fraud Internal fundermines the reputation of an establishment.
In case of negligence or lack of control, the hospital can also be held responsible. These scandals can reduce public funding or patient confidence.
It is essential to establish regular and independent audits financial, logistical and medical services.
Hospitals must also set up a double check of sensitive documents (invoices, prescriptions, order forms).
To learn more about the controls to be put in place, listen to our podcast with Marc Scholler, Deputy Director of Health Insurance in charge of Finances, Fraud Control & Audit !
AI and automation solutions can analyze thousands of documents to detect anomalies, duplicates, or inconsistencies.
Finovox, a platform specialized in the detection of false documents, automatically analyzes invoices, prescriptions or order forms to detect falsifications.
Thanks to its powerful algorithms and artificial intelligence, it allows hospitals to gain in reactivity and to identify anomalies invisible to the human eye in a few seconds.
Do you want to protect your establishment against internal fraud? Contact our Finovox experts today.
