Medical service inspections - Inspections of pharmacists' activities

The French health insurance funds are currently stepping up checks on healthcare professionals, particularly pharmacists.

These activity checks are likely to be triggered by the detection of atypical activity, as part of a thematic program, or even by an alert.  

In the majority of cases, analyses carried out by the medical department (or the administrative funds) reveal a number of anomalies involving non-compliance with legislative, regulatory and/or contractual rules.

The undue payments likely to result can be significant, and the penalties particularly severe, with some pharmacists finding themselves in extremely delicate situations.

Particular care must be taken at this stage, to minimize the "bill" to be paid and the risks of litigation.

With this in mind, it is important not only to question the regularity of the control, but also to provide exhaustive justification for any anomalies found.

How does a medical service inspection work?

Medical examination is strictly regulated by the French Social Security Code.

The medical department has extensive powers: not only can it carry out documentary checks, using data from the health insurance information system, but it can also consult patients' medical files, and hear and examine patients in order to check the reality of the procedures performed.

However, its powers are not limited: the business analysis procedure must respect the rights of the defence.

The pharmacist will be informed by registered letter with acknowledgement of receipt of the date of the inspection, and will be able to communicate all documents, procedures, prescriptions and other information relating to his activity. Note that in the event of suspected fraud, the medical service is not bound by this obligation to provide information.

At the end of the inspection, the medical department will notify the CPAM concerned and the practitioner of the anomalies found. The CPAM will then notify the practitioner of the grievances.

The grievances levelled against a pharmacist can be numerous, and are typically as follows:

- Abusive invoicing

- Invoicing for undispensed drugs

- Billing for non-prescription drugs

- Invoicing for drugs dispensed in a way that does not comply with the AMM

- Deliveries in excess of the quantity required for the prescribed treatment over the period

- Issuance of restricted prescription drugs initiated or renewed outside jurisdiction

- Unauthorized renewals

- No prescription

- Falsified prescriptions

- Unjustified duplication of prescriptions

- Deliveries of narcotics or similar substances without a secure prescription

The pharmacist will be given the opportunity to explain these grievances at a meeting to be held within one month. This meeting must be carefully prepared, as it is the pharmacist's first opportunity to contest the complaint, before any possible litigation.

A report of the interview will then be sent to the pharmacist by registered letter with acknowledgement of receipt within 15 days. The pharmacist has a further 15 days to return the signed report, together with any reservations. Failing this, the report will be deemed approved. Once again, the pharmacist must examine the report with the utmost diligence.

What happens after a medical service check?

On expiry of the latter period, the CPAM concerned will have 3 months to inform the claimant whether or not it intends to pursue the claim. Silence will constitute a waiver of prosecution.

 Should she decide to sue the pharmacist, various procedures may be implemented, including :

- an action for recovery of undue payment,

- referral to professional bodies,

- a conventional or penal procedure, or financial penalties.

‍

These outcomes can be serious and particularly costly for the pharmacies concerned. They will also require external support to effectively defend the professional.

‍

‍