They were five, at the beginning of 2023. On Monday August 21, thirteen other health centers were pinned for fraud that health insurance decided to sanction. For five years, the care provided by these member centers of the Alliance Vision network will be covered by Social Security on a very low basis. For example, for an ophthalmology consultation at €30, only the “authority rate” will be reimbursed, ie €1.22.
“Health insurance is determined to stop the fraudulent excesses of certain actors who are to the detriment of all: the community, the patients but also the professionals who respect the rules”, welcomed Thomas Fatôme, director of the Medicare, in a statement. According to the public body, the damage could amount to 21 million euros. Twenty-seven complaints were filed by the primary funds of these centers located in nine different regions, ranging from Île-de-France to Centre-Val de Loire.
Abuses that affect the quality of care
These ophthalmological and dental centers are accused of billing for fictitious acts, overbilling of acts, unsuitable prescriptions… “A patient could, for example, be prescribed glasses to multiply his appointments when that was not what he needed. need”, illustrates Thierry Bour, president of the National Union of Ophthalmologists of France (SNOF). In these cases, frequent recourse to third-party payment – a system in which health insurance pays the healthcare professional directly – prevents the patient from realizing the amount of care billed to him.
Since the Bachelot law of 2009, which aimed to promote the installation of practitioners in under-resourced areas, these health centers can be created easily, under a non-profit association model governed by the 1901 law. 2018. “Before, the management of these establishments was reserved for caregivers. But the State has opened this function to all profiles, ranging from bakers to opticians! “, laments the ophthalmologist.
New techniques then difficult to detect by health insurance have appeared in these centers, with the aim of reaping profits. “The owners of the walls of the association, for example, overcharged the external service providers who rent health equipment to earn money, points out Thierry Bour. The risk is to see our professions be discredited and the quality of care deteriorate. »
Establish a legislative framework and strengthen controls
Faced with the proliferation of these establishments since the health crisis, health insurance has increased its surveillance. “To date, nearly 130 health centers are or have been subject to checks, some of which belong to networks. In total, 32 criminal complaints have already been filed by the CPAMs, ”assures the health insurance.
Since May 21, 2023, a bill tabled by the new Minister for Disability Fadila Khattabi, at the time still a member of the Côte-d’Or (Renaissance), also aims to protect patients from these fraudulent practices. The text provides for example the possibility of prohibiting the opening of a new center to the manager of an establishment that has already been suspended or closed.
“When the possibility of creating these centers appeared, the excesses were not anticipated. Now, a legal framework is necessary”, insists the president of the SNOF.
Deserted centers forced to close their doors
For the time being, the Alliance Vision group disputes the facts of which it is accused. Once deconventioned, the thirteen pinned centers risk experiencing the same fate as the five establishments sanctioned at the start of the year, by being forced to close their doors in the face of an insufficient number of patients. “What attracts patients are quick appointments where the costs are not advanced,” observes Thierry Bour. People will not go to appointments where the consultation is hardly supported. »
The health center agreement signed on April 14, 2022 allows health insurance to initiate a simplified deconvention procedure, in the event of discovery of fictitious acts. At the same time, Social Security is also working with the justice system to create a register that will allow patients to identify the centers involved.