{"id":987756361,"date":"2024-06-02T08:38:53","date_gmt":"2024-06-02T07:38:53","guid":{"rendered":"https:\/\/p4h.world\/?post_type=news&p=987756361"},"modified":"2025-02-17T19:46:43","modified_gmt":"2025-02-17T18:46:43","slug":"resultats-de-laudit-2023-du-fonds-dassurance-maladie-pres-de-700-000-euros-reclames","status":"publish","type":"news","link":"https:\/\/p4h.world\/fr\/news\/resultats-de-laudit-2023-du-fonds-dassurance-maladie-pres-de-700-000-euros-reclames\/","title":{"rendered":"R\u00e9sultats de l’audit 2023 du Fonds d’assurance maladie : pr\u00e8s de 700 000 euros r\u00e9clam\u00e9s"},"content":{"rendered":"

[et_pb_section fb_built=”1″ admin_label=”! !! NE PAS MODIFIER ! !! ” _builder_version=”4.19.5″ _module_preset=”default” global_colors_info=”{}”][et_pb_row admin_label=”!!! PLEASE DO NOT EDIT !!!” _builder_version=”4.19.5″ _module_preset=”default” global_colors_info=”{}”][et_pb_column type=”4_4″ _builder_version=”4.19.5″ _module_preset=”default” global_colors_info=”{}”][et_pb_text admin_label=”TO BE EDITED – SUMMARY – Click on the WHEEL icon to open the textarea where you can paste or type your summary. The summary condenses the main points for the news that starts below. The summary is in bold and not longer than 300 characters, including spaces. The counter at the bottom can help.” _builder_version=”4.21.0″ _module_preset=”default” custom_padding=”||20px||false|false” global_colors_info=”{}”]<\/p>\n

L’ann\u00e9e derni\u00e8re, la Caisse d’assurance maladie a r\u00e9cup\u00e9r\u00e9 pr\u00e8s de 700 000 euros aupr\u00e8s des prestataires de soins de sant\u00e9 gr\u00e2ce \u00e0 un contr\u00f4le continu des demandes de remboursement. “Ce contr\u00f4le a permis de sensibiliser les partenaires \u00e0 la facturation des soins, r\u00e9duisant ainsi les demandes injustifi\u00e9es”, a d\u00e9clar\u00e9 Jelena Kont, chef du d\u00e9partement de supervision. <\/strong><\/p>\n

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La Caisse d’assurance maladie<\/strong> contr\u00f4le rigoureusement l’exactitude et la justification des demandes d’assurance maladie. L’ann\u00e9e derni\u00e8re, elle a r\u00e9clam\u00e9 pr\u00e8s de 700 000 euros<\/strong> aux prestataires de soins de sant\u00e9.<\/p>\n

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“Le contr\u00f4le continu du Fonds a permis de sensibiliser les partenaires aux pratiques de facturation et de r\u00e9duire les demandes injustifi\u00e9es, ce qui constitue une tendance positive”, a d\u00e9clar\u00e9 Jelena Kont, chef du d\u00e9partement de la supervision<\/strong>.<\/p>\n<\/blockquote>\n

Le service de contr\u00f4le analyse r\u00e9guli\u00e8rement la base de donn\u00e9es des factures m\u00e9dicales afin de v\u00e9rifier l’exactitude des factures de soins de sant\u00e9, des ordonnances \u00e0 prix r\u00e9duit et des certificats d’incapacit\u00e9. L’ann\u00e9e derni\u00e8re, pr\u00e8s de 32 500 factures<\/strong> ont \u00e9t\u00e9 examin\u00e9es, ce qui a permis d’identifier 3 198<\/strong> demandes injustifi\u00e9es<\/strong> d’une valeur de 170 305 euros.<\/strong> La pratique consistant \u00e0 permettre aux prestataires de corriger les erreurs et de r\u00e9utiliser les fonds a am\u00e9lior\u00e9 l’efficacit\u00e9. <\/p>\n

En 2022, 213 recours<\/strong> et plaintes ont donn\u00e9 lieu \u00e0 226 examens de dossiers<\/strong>, y compris des v\u00e9rifications aupr\u00e8s de plusieurs institutions. Les demandes de v\u00e9rification des certificats d’incapacit\u00e9 de travail ont augment\u00e9 de mani\u00e8re significative. Sur 252 certificats<\/strong> contr\u00f4l\u00e9s, 72 \u00e9taient injustifi\u00e9s<\/strong>, ce qui a donn\u00e9 lieu \u00e0 des r\u00e9clamations d’un montant de 19 989 euros.<\/strong> <\/p>\n

En outre, les litiges concernant les factures soumises via le portail de sant\u00e9 ont \u00e9t\u00e9 trait\u00e9s 90 fois, tandis que les activit\u00e9s li\u00e9es \u00e0 l’exactitude des prescriptions ont \u00e9t\u00e9 v\u00e9rifi\u00e9es dix fois, ce qui a donn\u00e9 lieu \u00e0 des r\u00e9clamations d’un montant de 4 276 euros.<\/strong><\/p>\n

Dix examens cibl\u00e9s ont \u00e9t\u00e9 effectu\u00e9s pour comparer les factures m\u00e9dicales avec les dossiers des patients, afin de s’assurer que les services \u00e9taient correctement document\u00e9s et justifi\u00e9s.<\/p>\n

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“Les efforts de supervision am\u00e9liorent la qualit\u00e9 de la documentation des services et l’exactitude de la facturation. De nombreux remboursements r\u00e9sultent d’erreurs involontaires, telles que des erreurs de codage ou de d\u00e9claration. Cependant, la fraude syst\u00e9matique entra\u00eene des p\u00e9nalit\u00e9s, la r\u00e9siliation du contrat et l’intervention \u00e9ventuelle de la police”, a soulign\u00e9 M. Kont<\/strong>.<\/p>\n<\/blockquote>\n

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L’ann\u00e9e derni\u00e8re, la Caisse d’assurance maladie a r\u00e9cup\u00e9r\u00e9 pr\u00e8s de 700 000 euros aupr\u00e8s des prestataires de soins de sant\u00e9 gr\u00e2ce \u00e0 un contr\u00f4le continu des demandes de remboursement. “Ce contr\u00f4le a permis de sensibiliser les partenaires \u00e0 la facturation des soins, r\u00e9duisant ainsi les demandes injustifi\u00e9es”, a d\u00e9clar\u00e9 Jelena Kont, chef du d\u00e9partement de…<\/p>\n","protected":false},"author":137,"featured_media":987756356,"comment_status":"closed","ping_status":"closed","template":"","meta":{"_et_pb_use_builder":"on","_et_pb_old_content":"","_et_gb_content_width":""},"categories":[],"tags":[2454,3070,2363],"acf":[],"_links":{"self":[{"href":"https:\/\/p4h.world\/fr\/wp-json\/wp\/v2\/news\/987756361"}],"collection":[{"href":"https:\/\/p4h.world\/fr\/wp-json\/wp\/v2\/news"}],"about":[{"href":"https:\/\/p4h.world\/fr\/wp-json\/wp\/v2\/types\/news"}],"author":[{"embeddable":true,"href":"https:\/\/p4h.world\/fr\/wp-json\/wp\/v2\/users\/137"}],"replies":[{"embeddable":true,"href":"https:\/\/p4h.world\/fr\/wp-json\/wp\/v2\/comments?post=987756361"}],"version-history":[{"count":16,"href":"https:\/\/p4h.world\/fr\/wp-json\/wp\/v2\/news\/987756361\/revisions"}],"predecessor-version":[{"id":987758802,"href":"https:\/\/p4h.world\/fr\/wp-json\/wp\/v2\/news\/987756361\/revisions\/987758802"}],"wp:featuredmedia":[{"embeddable":true,"href":"https:\/\/p4h.world\/fr\/wp-json\/wp\/v2\/media\/987756356"}],"wp:attachment":[{"href":"https:\/\/p4h.world\/fr\/wp-json\/wp\/v2\/media?parent=987756361"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/p4h.world\/fr\/wp-json\/wp\/v2\/categories?post=987756361"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/p4h.world\/fr\/wp-json\/wp\/v2\/tags?post=987756361"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}