SURVEY FRANCE 2. Health insurance files a complaint for fraud against several ophthalmological centers

Medicare will not turn a blind eye to ophthalmology health centers. It has just completed a series of checks on some of these establishments, suspected of fraud in the billing of medical acts. The organization is preparing to file four new criminal complaints, he announced to France 2’s “L’Œil du 20 heures”. These procedures are in addition to 12 other complaints already registered this summer, as announced Le Figaro, for “fraud, forgery and use of false and false declarations”. In total, the damage is estimated at 3.6 million euros since October 2020, according to Social Security. Fifty other centers are closely monitored.

See the investigation of “L’Œil du 20 heures”:

These establishments specializing in ophthalmology, which offer quick appointments, generally by third-party payment (without any advance payment for the patient), have increased in number over the past three years, thanks in particular to relaxed regulations on the conditions of creation of health centers. There are about 150 in France today, according to Health Insurance, which has noted a strong evolution of the costs linked to these establishments.

In 2020, these centers charged an average of 96.50 euros per patient, some even collecting an average basket of more than 150 euros, when a liberal ophthalmology and orthoptic practice charged an average of 63.50 euros per patient. “These are routine first-level care, there is no explanation for these cost differences”explains to “The eye from 8 p.m. “doctor Catherine Bismuth, director of the fight against fraud at Medicare.

“We found that a certain number of health centers had a heavy hand with abuse in acts, or ‘optimized’ invoicing, but above all we identified atypical invoicing that was highly suspicious of fraudulent practices”, explains the director. In question, for example, a practice called “false revoyure”, which consists of invoicing a first series of acts on the day of care, then a second until several months later, when the patient has not returned. Or the billing of a whole family, when only one person went to the consultation.

It is difficult for the patient to realize this at the time, because these acts are automatically transmitted to Social Security and to mutual insurance companies, without him advancing any costs out of his pocket.

Social Security recommends everyone to regularly consult the statements posted online in the personal space, and to alert their primary health insurance fund if there is the slightest problem. Finally, to go to a trusted establishment, it is better to seek advice from your doctor.

Health Insurance report on the evolution of expenses and products, July 2020, section “Analyze the atypical practices of certain health centers”, page 91

National Union of Ophthalmologists of France

Non-exhaustive list

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