Health insurance fraud 

Health insurance fraud takes a variety of forms because of the diversity of healthcare expenditure covered. Given the growing scale of expenditure, insurers face major challenges in preventing and detecting fraud. How does health insurance fraud develop? What reforms, strategies and technologies have been put in place to combat it? We take a closer look in this article.

What is Social Security?

Social security is a set of devices audiences financed by the State. 

Its purpose is to cover social risks such as disability, death, old age and maternity for employees, the self-employed and the liberal professions. 

Its aim is to ensure that everyone has the means to support himself and his family in decent conditions. 

Social security is based on the principle of solidarity financing adapted to each person's resources. It is organised into three separate schemes : 

• The general scheme
• The agricultural scheme
• Special schemes

General scheme: definition 

According to Public lifethe general scheme concerns 88% of the French population. It is managed by specialised bodies under the supervision of the State.
Today, the general scheme is divided into 5 main branches : 

• Disease It is responsible for covering healthcare costs and guaranteeing access to care. Its central fund is the CNAM.
• Work-related accidents and illnesses It is dedicated to managing occupational risks such as accidents at work. Its central fund is also the CNAM.
• Family It is responsible for managing family benefits to reduce disparities in living standards. Its central fund is the CNAF.
• Retirement It is responsible for paying pensions to retirees. Its central fund is the CNAV.
• Dues and collection It is responsible for collecting social security contributions from companies and individuals. Its central fund is URSSAF.

The agricultural scheme: definition 

The agricultural scheme differs from the general scheme in that it is organised into separate branches. Its aim? To insure the healththe maternity and some retirement for farmers and farm workers. 

Unlike beneficiaries under the general scheme, farmers only receive compensation in the event of an accident at work, and are not covered for sickness.

Special schemes: definition 

These schemes are based on a rule of solidarity restricted to each profession. They are broken down into 3 categories :

• There public service 
• THE companies and public institutions 
• THE professions or companies specific such as notary clerks and miners, or RATP and EDF.

Please note that each special scheme has its own terms of cover and organisation.

Social security and health insurance: what are the differences? 

Assurance Maladie is in fact a integral part of the Social Security system. It includes health branch as well as Accidents at work and occupational illnesses (AT/MP) branch. The whole system forms Health Insurance and is managed by the Caisse Nationale d'Assurance Maladie (CNAM).

This insurance covers hospital costs, medicines and treatments for illnesses. Like Social Security, CNAM membership is compulsory for all French citizens! 

Want to find out more about the insurance industry? Go to our article focus on the different insurance sectors !

The development of health insurance fraud

Health insurance covers a wide range of expenses, which is why there are various forms of fraud. They can range from identity theft, to falsifying work permits, to trafficking in medicines. 

In France today, there are almost 65 million policyholders in Franceseveral hundreds of thousands of self-employed healthcare professionals and more than one million companies. 

Fraudsters are not just individuals, but also professionals who take advantage of their benefits. It is now estimated that 8 out of 10 fraud cases are committed by healthcare professionals.

Health insurance fraud among individuals 

Social security fraud is a relatively simple act for policyholders. But what is health insurance fraud? 

It is generally accepted that fraud occurs when the insured : 

• Falsifies documents such as work stoppages, medical prescriptions, treatment forms or medical certificates to obtain an undue advantage. 
• Declare a false change of situation which gives them access to attractive benefits
• Uses another person's carte vitale to obtain medicines 
• Provides false information when applying for social security benefits 

Health insurance fraud among professionals 

Individuals are not the only ones to commit health insurance fraud! 

According to the Court of Auditors, 80 % of fraud is committed by professionals. They take advantage of their legitimacy to bill for imaginary services, reimburse care and medicines or overcharge for services. 

Protecting yourself against health insurance fraud

Combating fraud is very important today, because it diverts part of the financial resources intended for patient care. 

To arm itself against fraud, the Assurance Maladie has several means of detection and control. These include risk assessment and the use of new technologies. We take a look at the resources available to combat document fraud. 

New reforms for health insurance 

On Wednesday 20 March 2024, Prime Minister Gabriel Attal relaunched the plan to merge the carte vitale and the identity card. Its aim? To combat health insurance fraud. 

Nevertheless, one major point is currently being debated: the confidentiality of information. With a single card, an individual has access to more data: identity and social security number. 

For the moment, the government appears to be acting on the recommendations provided by the Commission Nationale de l'Informatique et des Libertés (CNIL) (French Data Protection Authority)The aim is to split the electronic chip into two independent parts. On the one hand, there would be civil status information, including surname, forename, address, date and place of birth, and on the other, health information, i.e. the social security number. 

Watch this space in the coming months! 

Set up internal control systems

To guard against health insurance fraud, the CNAM and insurance companies (such as mutual insurers and provident institutions) can set up internal control systems. 

For example, they may carry out regular audits to ensure the integrity and transparency of past transactions. Companies can carry out internal analyses of refund claims, THE medical records or the financial transaction invoices. 

To find out more, read our article : 3 ways to empower your anti-fraud team 

Preventing fraud through collaboration and information sharing 

Working closely with government agencies, healthcare providers and insurers can be very beneficial. It allows you to share information and practices on the fight against fraud. 

Collaboration can lead to 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, for example by approaching the CNAM.

Relying on advanced technologies 

Insurance companies can take advantage of new technologies to fight against fraud. document fraud. 

Adopting advanced technological solutions such aspredictive analysisthe biometrics and fraud detection tools based on theartificial intelligence can be a useful tool in the fight against fraud. 

These technologies can help automate detection processes and improve the effectiveness of anti-fraud programmes.

At Finovox, we offer you a anti-fraud solution available in SaaS or API. It enables companies to detect and explain all types of document fraud. The solution is based on proprietary artificial intelligence that analyses the data structure, THE metadata and the consistency of information extracted from the documents.

What's more? Thanks to Finovox, you can retrieve the full analysis via a summary sheet available in PDF format. 

Contact our experts to find out more!