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09/05/2019

Medical check-ups: an effective tool that still needs to be improved

The “Social Security” monitoring visits are not a myth. “However, they are not systematic and of the 7 million work stoppages per year, i.e. 234 million compensated days, less than a quarter are monitored by the Social Security system,” says Jean-Marc Esvant, Director of Social Protection at Verlingue. Visits are made to the home of the employee on sick leave. In practice, the inspector sworn in by the Health Insurance Company checks that the person is present at home and that the work stoppage is still medically justified on the day of the inspection.

 

This “physical” control is of course carried out outside the authorised exit times. Unless an exemption is granted by the prescribing doctor for the work stoppage, the insured person is required not to leave their home from 9 a.m. to 11 a.m. and from 2 p.m. to 4 p.m. every day (including at weekends), unless they are required to undergo examinations and/or seek medical care.

 

In the event of an employee’s unjustified absence from their dwelling during visiting hours, or a stoppage deemed unjustified or no longer justified, the primary health insurance fund (CPAM) may suspend the payment of daily allowances (IJ). As there is a limited number of inspectors, inspections are, as we have seen, very rare. In addition, they are focused on long or repetitive sick leave. At the end of the fifth stoppage of less than fifteen days, the CPAM’s medical officer generally initiates an inspection procedure. However, many other cases are not dealt with, in particular occasional “complacent” judgements.

 

Outsourced counter-visits. It is precisely to fill this gap that companies, especially large groups, have developed the habit of conducting their own work stoppage inspections, also known as “counter-visits”. This is completely legal, provided that the employer pays the employee daily allowances in addition to those of the health insurance scheme. Companies use specialized service providers, such as Securex, AXMedica or SMP.

 

Insurers (mutuals, accident cover institutions and insurance companies), which pay the additional daily allowances, have also started to do so. “Medical examination is a necessary and effective procedure. It is one of the tools that we systematically offer to companies and it is accepted by social partners, in a way that respects medical confidentiality,” explains Jean-Marc Esvant. “These inspections are combined with preventive measures for greater efficiency.” Because, against all expectations, trade unions do not necessarily take a negative view of counter-visits. They have understood that unjustified stoppages result in a cost for the company and, in most cases, an increase in work for the employees present. Which is not good for anyone.

 

Here too, insurers outsource this task. “For work stoppage inspections, we use a specialised company,” confirms Christophe Scherrer, Deputy Managing Director at Malakoff Médéric Humanis. In line with the principle of social security, the payment of additional daily allowances may be suspended if the employee is not present during visiting hours or if the stoppage is not justified on medical grounds. The inspecting doctor from the supplementary health insurance organisation or accident cover institution shall then notify the CPAM’s medical adviser by letter.

 

Lack of gateways. This may sound crazy, but this type of situation rarely leads to basic daily allowances being suspended. A health insurance inspector must personally report the employee’s absence before the CPAM stops paying benefits. As a result, an employee may no longer receive additional IJs while continuing to receive… their basic daily allowances. It is nonsensical! “The Berard-Oustric-Seiller report submitted to the Prime Minister in March on this issue recommends that the inspection system be reviewed and that bridges be built between Social Security, corporate and insurance inspections. We would do well to share the findings,” says Jean-Marc Esvant of Verlingue.

 

One could very well imagine a system similar to that of NOEMIE (open standard for sickness exchanges with external stakeholders) which has long allowed for the remote transmission of information on health care expenditure between the Health Insurance and complementary health services. With the exception that exchanges should be in both directions. There is also the tricky issue of personal data protection.

 

 

Jean-Philippe Dubosc – L’Opinion