Pre-litigation phase monitoring of healthcare professionals' activity

Primary health insurance funds (CPAM) have the power to monitor the activities and acts of healthcare professionals, particularly doctors and dental surgeons, which can lead to disciplinary proceedings and requests for reimbursement of undue payments. Properly managing the pre-litigation phase is essential to best ensure the defense of the monitored doctor.

The contentious phase is very often preceded by a technical inspection carried out by a medical advisor belonging to the medical control service of the health insurance.

As part of this activity monitoring, the medical control service must follow a strict procedure, as provided for in the Social Security Code.

First of all, it is important to specify that all correspondence sent by social security organizations must be kept (with envelopes and return receipts).

The check carried out by the medical control service is often triggered when the processing of radiological images, SNIR reports, or activity reports do not match local averages or in the context of a complaint from a patient and will cover all acts performed for a given period of activity.

If the medical advisor wishes to hear and examine some of the controlled doctor's patients, the medical advisor must imperatively send a list of the patients concerned (Article R.315-1-1 of the Social Security Code “CSS”)

The control itself is not subject to any deadline and can extend over several months.

When the medical control service has noted breaches of legislative, regulatory or contractual rules, it informs the health insurance fund, which may then notify the healthcare professional of the grievances held against them, by registered letter with acknowledgment of receipt.

The professional under review may then request an interview with the medical review service within one month of notification of the grievances. (Article R.315-1-2 CSS)

Prior to the interview, the medical control service must provide the healthcare professional being audited with all the information necessary to prepare for this interview, including in particular the list of facts alleged against the professional and the identity of the patients concerned. (Article D.315-2 of the CSS)

It is strongly advised at this stage to be assisted by a lawyer for the preparation of this interview and by another doctor during this interview, in order to be best able to present a solid defense, as it is essential to respond to all the grievances raised.

At the end of the interview, a report is sent by registered letter with acknowledgment of receipt to the healthcare professional within fifteen days. From receipt, the healthcare professional has fifteen days to return this signed report, along with any reservations. Failing this, it will be deemed approved. (Article D.315-2 of the CSS)

It is again very important to record the reservations in writing, i.e. the medical observations raised during the interview against the grievances that would have been maintained by the control service and, in parallel, to be assisted by a lawyer in order to provide a legal response and to raise any potential failures in the control procedure.

Finally, upon expiration of the 15-day period to assert reservations, the social security organization has a period of three months to inform the controlled doctor of the actions it intends to take regarding the grievances initially notified. (Article D.315-3 CSS)

Otherwise, the social security body will be deemed to have renounced pursuing the controlled healthcare professional (except in the event of a complaint).

After the inspection, several procedures may then be implemented by the CPAM, namely, first, the recovery of the overpayment for the anomalies observed, and financial penalties. The CPAM may also file a complaint before the social insurance section or before the Disciplinary Chamber (or both) of the Order Council to which the controlled doctor belongs.

 

Health Law