Health Insurance scams take different forms due to the diversity of health expenses covered. Faced with the growing scale of expenses, insurance organizations face major challenges in preventing and detecting fraud. How does health insurance fraud develop? What are the various reforms, strategies and technologies put in place to fight against these frauds? We take stock together in this article.
Social Security is a set of devices publics financed by the State.
It aims to ensure the coverage of social risks such as disability, death, death, old age or maternity for employees, the self-employed as well as for the liberal professions.
Its objective is to guarantee everyone the means necessary to provide for himself and his family in decent conditions.
Social Security is based on a principle of solidarity financing adapted to everyone's resources. It is organized in three distinct regimes :
According to Public life, the general regime concerns 88% of the French population. It is managed by specialized organizations under the supervision of the State.
Today, the general diet is divided into 5 main branches :
💡Did you know that?
Security is implemented in post-war period, in 1945 exactly. Its creation allows the establishment of a single regime for the French population.
The agricultural system differs from the general system in that it is organized without distinct branches. Its purpose? Insure the sectors of health, of the motherhood And of the superannuation For the farmers and agricultural employees.
Unlike beneficiaries of the general scheme, farmers only receive benefits in the event of an accident at work and are not covered for illness.
These regimes are based on a rule of solidarity restricted to each profession. They come in 3 categories :
Note that each special plan has its own coverage terms and organization.
Health Insurance is actually a integral part of Social Security. It includes the Branch disease as well as the Occupational accidents - occupational diseases branch (AT/MP). The whole forms Health Insurance and is managed by the National Health Insurance Fund (CNAM).
This insurance covers hospital expenses, medications, and treatments required for illnesses. Just like Social Security, membership in CNAM is an obligation for all French people!
Do you want to learn more about insurance players? Direction our article Focus on the different insurance sectors !
Health expenses covered by Health Insurance are numerous, which is why there are various forms of fraud. They can range from identity theft, through the falsification of work stoppages, to drug trafficking.
Today, in France, there are nearly 65 million insured persons in France, several hundreds of thousands of liberal health professionals And more than one million businesses.
Fraudsters are not only individuals but also professionals who take advantage of their benefits. It is now estimated that 8 out of 10 frauds are committed by a health professional.
Social Security fraud is a relatively simple act for insured persons. But what do we mean by health insurance fraud?
It is commonly accepted that one can speak of fraud as soon as the insured person:
Individuals are not the only ones to defraud health insurance!
According to the Court of Auditors, 80% of fraud is committed by professionals. They take advantage of their legitimacy to charge imaginary benefits, reimburse treatments and medications or overcharge benefits.
Fighting against fraud is very important today because it diverts part of the financial resources intended for the care of patients.
In order to arm itself against fraud, Health Insurance has several means of detection and control. For example, we can mention risk assessment or the exploitation of new technologies. We take stock of the means available to fight against documentary fraud.
On Wednesday 20 March 2024, the Prime Minister, Gabriel Attal, relaunched the Proposed merger between the Carte Vitale and the Identity Card. Its purpose? Fight against health insurance fraud.
However, one major point is currently under debate, the confidentiality of information. In fact, in possession of one and the same card, an individual has access to more data: identity and social security number.
For the moment, the government seems to be taking action on the recommendations provided by the National Commission for Information Technology and Freedoms (CNIL), namely, to split the electronic chip into two independent parts. There would then be on the one hand the civil status including the name, first name, address, date and place of birth and on the other hand the information relating to health, i.e. the social security number.
To be continued in the coming months!
To protect themselves from health insurance fraud, CNAM and insurance companies (such as mutual insurance companies or pension institutions) can set up internal control systems.
For example, they can carry out regular audits in order to guarantee the integrity and transparency of the various past transactions. Companies can analyze internally the refund requests, the medical records or even the financial transaction invoices.
To learn more, read our article: 3 ways to empower your anti-fraud team
Working closely with government agencies, health care providers, insurers can be very beneficial. This allows you to sharing information and practices about the fight against fraud.
Collaboration can allow for a more effective and coordinated response to fraudulent activities.
It should be noted that fraud experts in the health sector are increasingly seeking this cooperation by requesting, for example, CNAM.
Insurance companies can rely on new technologies to fight against document fraud.
In fact, adopting advanced technological solutions such as thepredictive analytics, the biometrics and fraud detection tools based onartificial intelligence can be useful in the fight against fraud.
These technologies can help automate detection processes and improve the effectiveness of anti-fraud programs.
At Finovox, we offer you a anti-fraud solution available in format SaaS or API. It allows businesses to detect and explain any type of document fraud. The solution is based on a proprietary artificial intelligence that analyzes the data structure, the metadata And the consistency of information extracted from the documents.
The most? Thanks to Finovox, you get the complete analysis via a summary sheet available in PDF format.
Contact our experts to find out!
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