Fraud does not spare health insurance.
Dental care and prostheses give rise to misappropriations which represent significant sums, without the means of combating always being commensurate with the risk.
Insurers on the front line of fraud:
A complementary mutual fund became aware of the phenomenon following the recruitment of an internal control officer from the banking sector. After a few weeks of presence, the control manager came to see her director to tell her: “I think we have significant fraud. » When the mutual fund launched in-depth checks in mid-2017 on dental services, it noticed a significant number of undue reimbursements.
“We don’t want to repay less, but repay fairly”, says the general director.
Since we implemented the controls, we have avoided unduly spending an amount of around €2 million.
It is enormous ! » “We have a culture of payment in mutual societies,” explains the president.
We have turned a blind eye for too long.
But now it's over! We are not going to let abusive practices continue. »
Insurers have not yet assessed fraud
According to a study by the firm Optimind Winter of September 2017 with 25 stakeholders, most insurance and mutual insurance companies underestimate health fraud, or are even unaware of it.
A figure speaks for itself: only five out of the 25 interviewed have a team of more than five people to fight against fraud!
By comparing figures for all insurers, dental fraud would amount to more than €100 million per year.
“Fraud especially strikes where there is a bill”: The and optical cover,
These are a lot of bills that we get reimbursed by our supplementary health insurance.
Some dentists take advantage of it, explains an investigator working for the insurance company.
Faced with these slippages, one of the obviously legitimate constraints is medical confidentiality.
This is why, in order to be able to question patients or request proof of actions from dentists, many complementary health insurance companies have recruited “consultant dental surgeons”, an initiative which arouses real hostility among the medical profession.
Le doctor Richard Régnier is a pioneer among these dentists who consult insurers.
His twenty years spent tracking down the bad practices of his colleagues have not only attracted him with sympathy.
That's an understatement:
Furious that the consultant dental surgeon, who still practices privately, asked her for “an assessment, an X-ray and a diagnosis of the treatments she carried out”, a colleague threatened to attack her before the council of the Order for “anti-confraternal attitude”.
Some companies are now equipped with software to identify suspicious reimbursements.
On a closed Facebook group for discussions between dentists, she is very insulting towards Richard Régnier
“pathetic who doesn’t even have a DU (Editor’s note: university diploma)”
and his case aroused many reactions from other dentists.
“Personally, I would answer him: you have no right to question my treatment plan. If you wanted to treat patients, you shouldn't get paid and become a slave to a mutual insurance company."
writes one of them while another proposes that a union cover transport and hotel costs in the event of a complaint being filed.
Richard Regnier bursts out laughing: “Brotherhood is beautiful, isn’t it? However, I have 44 years of private practice... I produced these exchanges during the hearing before the Council of the Order and the matter was quickly resolved. »
Even recently, the leader of one of the largest dental unions was very critical of so-called consultant dentists and spoke of “patients being held hostage” which is clearly not the case.
under cover of medical confidentiality which only serves to mask the commercial practice of dental prostheses by dental practices (formally prohibited) to the detriment of patients and mutual insurance companies.
And even the councils of the Departmental Order of Bas-Rhin and Haut-Rhin would not be very favorable to these dentists like no other.
“What is impressive is to see how these two councils of the Order are turning against the function of consultant dentist, and refusing to take a position on issues. They are still supposed to be guarantors of ethics,” notes Christine Coléno, of the MCA. A vision, however, contested by those concerned. Contacted, the heads of the two orders of Bas-Rhin and Haut-Rhin affirm that the complaints only concern very few practitioners (less than 2%) and that they are treated with diligence and efficiency, (an amount announced which remains improbable ). Whatever the case, everything still remains very opaque on the part of the councils of the Dental Order.
Sources and references to argus de l’assurance articles:
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