L\u2019Inspection g\u00e9n\u00e9rale des finances (IGF) et l\u2019Inspection g\u00e9n\u00e9rale des affaires sociales (IGAS), avec la participation notamment de Mireille Ga\u00fcz\u00e8re, Fr\u00e9d\u00e9ric Turblin, Jean-Philippe Vinquant, Esther Devillers, Anne-Michelle Basteri, \u00c9milie Maysonnave, Arturo Garcia-Gonzalez et Mouad El Issami, ont conduit une revue des d\u00e9penses li\u00e9es \u00e0 la fraude en mati\u00e8re de prescriptions et de facturation \u00e0 l\u2019Assurance maladie. Cette analyse s\u2019inscrit dans un contexte o\u00f9 les d\u00e9penses du r\u00e9gime g\u00e9n\u00e9ral d\u2019assurance maladie devraient atteindre 244 milliards d\u2019euros en 2024.<\/p>\n
Le rapport estime que la fraude d\u00e9tect\u00e9e s\u2019\u00e9l\u00e8ve \u00e0 628 millions d\u2019euros, dont 70 % sont imputables \u00e0 des professionnels de sant\u00e9 ou \u00e0 des personnes usurpant une identit\u00e9 ou en utilisant une fausse identit\u00e9. Cette fraude se d\u00e9veloppe dans un contexte marqu\u00e9 par la g\u00e9n\u00e9ralisation du tiers payant depuis 2016 et la rapidit\u00e9 des remboursements, qui cr\u00e9ent des vuln\u00e9rabilit\u00e9s dans la cha\u00eene de paiement de l\u2019Assurance maladie. Si les r\u00e9sultats en mati\u00e8re de d\u00e9tection de la fraude se sont nettement am\u00e9lior\u00e9s ces derni\u00e8res ann\u00e9es, la r\u00e9cup\u00e9ration des indus reste limit\u00e9e : seule la moiti\u00e9 des montants frauduleux d\u00e9tect\u00e9s est effectivement recouvr\u00e9e.<\/p>\n
Les inspections pr\u00e9conisent une r\u00e9orientation strat\u00e9gique des contr\u00f4les, en passant de contr\u00f4les a posteriori \u00e0 des contr\u00f4les en amont du paiement. Il s\u2019agit notamment d\u2019acc\u00e9l\u00e9rer l\u2019int\u00e9gration de contr\u00f4les automatis\u00e9s dans le syst\u00e8me de paiement, afin de rejeter les paiements indus avant leur versement, et de d\u00e9finir une feuille de route pour le d\u00e9ploiement de l\u2019ordonnance num\u00e9rique, pr\u00e9sent\u00e9e comme un outil cl\u00e9 pour s\u00e9curiser la cha\u00eene de prescription et lutter contre les ordonnances falsifi\u00e9es. Le rapport recommande \u00e9galement d\u2019optimiser le ciblage des contr\u00f4les gr\u00e2ce \u00e0 une utilisation accrue des outils de data science, afin d\u2019identifier plus rapidement les sch\u00e9mas \u00e9mergents de fraude, et de concentrer les contr\u00f4les sur les dossiers \u00e0 forts enjeux financiers, dans lesquels la fraude de professionnels de sant\u00e9 est surrepr\u00e9sent\u00e9e.<\/p>\n
Enfin, le rapport souligne la n\u00e9cessit\u00e9 de renforcer la coordination entre les caisses primaires d\u2019assurance maladie et les parquets, afin d\u2019am\u00e9liorer l\u2019efficacit\u00e9 du traitement judiciaire des fraudes. Ces orientations portent principalement sur la s\u00e9curisation des d\u00e9penses de sant\u00e9 et la performance des dispositifs de contr\u00f4le, avec des enjeux directs pour la soutenabilit\u00e9 financi\u00e8re de l\u2019Assurance maladie et l\u2019int\u00e9grit\u00e9 de la relation avec les professionnels de sant\u00e9.\u00a0(contenu r\u00e9sum\u00e9 par l’IA)\u200bLire la Suite<\/a><\/p>","protected":false},"excerpt":{"rendered":" L\u2019Inspection g\u00e9n\u00e9rale des finances (IGF) et l\u2019Inspection g\u00e9n\u00e9rale des affaires sociales (IGAS), avec la participation notamment de Mireille Ga\u00fcz\u00e8re, Fr\u00e9d\u00e9ric Turblin, Jean-Philippe Vinquant, Esther Devillers, Anne-Michelle Basteri, \u00c9milie Maysonnave, Arturo 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