Overbilling, fictitious acts, accumulation of examinations: an investigation by the Paris prosecutor's office has been targeting a network of ophthalmological centers since the summer of 2021 for suspicions of fraud estimated at more than 7 million euros, we learned on Monday from concordant sources, confirming information from the JDD.
As part of a "national control operation against twelve ophthalmological health centers belonging to a single network" launched in October 2020, "non-compliant billing practices" were revealed, according to a document from the National Health Insurance Fund (Cnam) consulted by AFP.
Among these fraudulent acts were discovered, among other things, "double billing to Health Insurance for the same act, fictitious acts, that is to say acts billed but not performed" or "invoicing of acts medically redundant whose accumulation is prohibited in the nomenclature”, is it detailed.
The financial damage is estimated "at more than seven million euros", announces in this document the Health Insurance.
Between June 2021 and June 2022, twenty-six complaints were filed against twelve centers located in Ile-de-France, Provence-Alpes-Côte d'Azur, Normandy, Hauts-de-France, Pays-de-la-Loire, Auvergne-Rhône-Alpes, Centre-Val-de-Loire and Grand Est.
A complaint for fraud was sent on September 15 to the Paris prosecutor's office, which centralizes all complaints, by the National Union of Ophthalmologists of France, its president, Doctor Thierry Bour, told AFP.
“Some of the centers are functioning normally but we have the impression that they are becoming a minority and that we are witnessing a generalization of excesses”, which undermines the credibility of the profession, denounced Doctor Bour.
A preliminary investigation was opened on July 6, 2021 for fraud and money laundering in an organized gang, the Paris prosecutor's office confirmed to AFP.
The investigations were entrusted to the Central Office for the Fight against Illegal Labor (OCLTI) and the Platform for the Identification of Criminal Assets (Piac), he said.
Searches were carried out in centers in Paris, Ile de France and in the provinces on December 13, 2021, added the prosecution.
“Hearings of personnel also took place” and the elements seized during the searches are being exploited, according to the Cnam.
Suspicions of fictitious acts
In addition, "eight other ophthalmological health centers, all located in Ile-de-France, are currently being checked by the health insurance services" and "the investigations have made it possible to confirm the suspicion of fictitious acts “, adds Health Insurance, announcing the upcoming filing of new criminal complaints.
The number of eye health centers receiving more than 500 patients has increased from 88 in 2015 to 157 in 2020, according to Cnam.
Noting "a 50% increase in the average cost of care per patient", a 250% increase in expenditure costs from 20 million euros in 2015 to 69 million euros in 2019 and reports of insured or health professionals, the Health Insurance has intensified its checks in the visual sector, particularly in these centres.
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