The General Inspectorate of Finance (IGF) and the General Inspectorate of Social Affairs (IGAS) have carried out a review of expenditure relating to fraud involving prescriptions and claims to the health insurance scheme.

Against a backdrop where expenditure under the general health insurance scheme is set to reach €244 billion in 2024, the fraud detected amounts to €628 million, 70 per cent of which is attributable to healthcare professionals or individuals impersonating others or falsifying their identity.

Health insurance fraud has arisen against a backdrop of the widespread introduction of third-party payment since 2016, combined with rapid reimbursement, creating vulnerabilities in the health insurance payment chain. Furthermore, whilst results in terms of fraud detection have improved significantly in recent years, the picture is more mixed when it comes to recovering overpayments, as only half of the sums involved are recovered.

To improve the fight against fraud, the report proposes several priority areas. It recommends a strategic shift from downstream to upstream payment controls: The report also suggests optimising controls and their targeting by making greater use of the potential offered by data science, in order to identify emerging fraudulent patterns. It proposes refocusing controls on cases with high financial stakes, where fraud by healthcare professionals is over-represented.

• by accelerating the integration of built-in controls into the payment system, to reject undue payments before they are made;
• by establishing a roadmap for the roll-out of digital prescriptions, a key tool for securing the prescription chain and combating forged prescriptions.

Finally, it is recommended that coordination between the primary health insurance funds and the public prosecutor’s offices be strengthened to ensure more effective legal action.