"After investigation, the Fifth People's Hospital of Taihe County (North District) is suspected of inducing hospitalization, false medical records, imposters, over-treatment, and unreasonable conditions such as'including food and housing, free physical examination, car pick-up and delivery, and lower admission standards'. Medication and other phenomena, the Department of Rehabilitation Medicine has reduced or exempted patients’ medical out-of-pocket expenses and subsidized meals. All patients admitted to the North District have subsidized meals, involving a violation amount of RMB 2,127,300." A few days ago, Fuyang City Medical Insurance Bureau in Anhui Province notified 5 Four hospitals including the Fifth People's Hospital of Taihe County (North District) were dismissed from their medical insurance settlement agreements, several doctors in charge were dealt with severely, and the violation amount was recovered.
The case is transferred to the public security organ for handling.
The medical insurance fund is the people's "medical money" and "life-saving money".
The reporter learned from the National Medical Insurance Bureau that in 2020, the national medical insurance system will carry out in-depth special treatment and unannounced inspections to combat fraud and insurance. A total of 390,000 illegal medical institutions were handled throughout the year, and 22.31 billion medical insurance funds were recovered.
What are the tricks of fraudulently obtaining medical insurance funds?
What role did some party cadres and public officials play in it?
How to establish and strengthen a long-term monitoring mechanism for collusion between internal and external medical institutions to defraud insurance coverage?
1 The diagnosis is false, the patient is acting, the ward is empty, and cases of medical insurance fund fraud and insurance fraud occur frequently
"Intermediary special vehicles collect the elderly and send them to the hospital", "Doctors' tailor-made" fake medical records", "Someone is hospitalized 9 times a year for free"... At the end of 2020, a number of medical institutions in Taihe County, Anhui Province were suspected of insurance fraud. The gray interest chain of collecting people in hospitals, hospitals inducing patients to be hospitalized, and fake patients receiving money for hospitalization has attracted widespread attention.
In fact, the fraudulent insurance incident that was exposed this time is not an isolated case.
In some cases, the diagnosis is false, the patient is acting, and the ward is empty.
In November 2018, two private hospitals in Shenyang, Liaoning Province, were exposed to fraudulently obtaining medical insurance funds by hiring "patients" for false hospitalization and falsifying medical records; in March 2019, 8 cases involving buying patients and defrauding medical insurance funds by Shuanglong Hospital in Fuyang City, Anhui Province The case was exposed; in July 2020, 5 cases of Ren'ai Hospital in Yuncheng, Shanxi Province, were exposed through hanging bed hospitalization and fraudulently defrauding medical insurance funds by defrauding medical service fees.
So, how does the gray interest chain of fraud and insurance work?
"Previous investigations and investigations have shown that after recruited personnel are hospitalized, the hospital will obtain illegal benefits by replacing drugs, prescribing physiotherapy items and times, hanging bed hospitalization, and false surgery." The case handler introduced, in accordance with relevant medical insurance regulations. After the insured is hospitalized, the reimbursement expenses are settled by the hospital and the medical insurance management department, and the reimbursement expenses from the false treatment will be included in the hospital.
Taking multiple medical institutions in Taihe County suspected of fraudulent insurance as an example, in accordance with the "Anhui Province Unified Urban and Rural Residents' Basic Medical Insurance and Critical Illness Insurance Benefits Implementation Plan (Trial)" and other relevant regulations, according to different hospital levels, urban and rural residents' basic medical insurance The hospitalization reimbursement rate ranges from 70% to 85%.
“In fact, the hospital’s income is more than this. Surplus medicines and disposable medical consumables generated through replacement medicines, false operations will be restocked, which is also not a small amount of income.” The case handler said, and these illegal A small part of the income is used to pay intermediaries and fake patients.
After a process, the hospitals, intermediaries, and fake patients all got the oil and water, but the people's medical insurance fund was cheated away while going around.
More than that, the medical insurance system involves multiple entities such as medical service providers, medical service demanders, and medical insurance fund management departments, with multiple links, long chains, multiple risk points, difficult supervision, and numerous fraudulent behaviors.
"Since 2020, through special governance and unannounced inspections, many medical institutions have found violations of regulations and laws, involving internal and external collusion to defraud medical insurance funds." According to the relevant person in charge of the Fund Supervision Department of the National Medical Insurance Administration, such as medical institutions and their staff fictional medicines Services, falsify medical documents and bills, swindle insurance with the insured person, or the medical institution and its staff provide false invoices for the insured person to swindle insurance, or the medical institution and its staff handle medical treatment for persons not covered by medical insurance Guarantee treatment fraud insurance and so on.
2 Individual party members, cadres and public officials participated in the event, colluding internally and externally to defraud medical insurance funds
"The single price of etanercept is very high. It is more economical to purchase etanercept through outpatient clinics, so I wanted to settle the cost of etanercept through hospitalization." In the fraud insurance involving public officials, it is similar to Chaiduo. It is not uncommon to take advantage of the position to facilitate theft by guards.
Chaiduo, the former president of the Fifth People's Hospital of Qinghai Province, needed to be injected with etanercept for treatment during his tenure.
After Chaiduo learned from the hospital pharmacy that the hospital had not purchased the drug, he arranged for the hospital to purchase etanercept.
How to reimburse non-medical insurance reimbursement drugs?
Chai Duo thought of hanging-bed hospitalization and swapping.
According to Tan Mou, the director of the health care department of the hospital who is responsible for handling the inpatient procedures for Chaiduo, “I will tell his (Chaiduo) resident doctor that the dean wants to change the medicine, so the resident will pay attention as much as possible when prescribing the medicine. Prescribe more medical insurance reimbursement drugs to maximize the proportion. When the drug cost for this hospitalization reaches almost 20,000 yuan, and time is not allowed to stay in bed, the person in our department will handle the discharge procedures for him."
The cost of medicine was exchanged with the same amount of medical insurance reimbursement medicines and self-paid medicines. As of March 2019, Chaiduo had used a total of 109 self-paid medicines, with a medical insurance fund of 221,270 yuan.
In 2020, Chaiduo, who has been "double-opened", was convicted of corruption and bribery. He was sentenced to 11 years in prison for several crimes and was fined 600,000 yuan.
"Party members, leading cadres and public officials participated in fraudulent insurance, including induction of hospitalization, fictitious services, cross-substitution of items, repeated charges, forged and false bills for reimbursement, fake medical treatment, use of social security cards to cash out or arbitrage medicines, consumables and other similar to ordinary personnel There are also situations such as theft by internal personnel, internal and external collusion, etc." The relevant person in charge of the Fund Supervision Department of the National Medical Insurance Administration introduced.
5 staff members of the medical insurance center in Yongcheng City, Henan Province used the convenience of changing the information of the insured persons, processing or canceling the formal and temporary medical insurance cards, and in just a few months, they successively revised the information of the 2011 suspended enrollees to In the designated medical insurance card, together with the bosses of 4 medical insurance designated pharmacies, the funds in the individual medical insurance accounts of the insured persons were stolen through the pharmacy medical insurance credit card system, totaling more than 1.73 million yuan.
“It is also common for medical institutions or their staff to apply for medical insurance benefits for people who are not covered by medical insurance to defraud medical insurance funds." Sun Moumou, a joint orthopedist at Kunshan Traditional Chinese Medicine Hospital in Jiangsu Province, assisted others in fraudulent use of the insured’s social insurance card, 10 Defrauded the medical insurance fund of 25,400 yuan within days.
The medical insurance department has recovered all the funds defrauded in accordance with relevant measures, and at the same time interviewed the director of the hospital and the director of the medical insurance office; canceled Sun’s medical insurance prescription qualification; included the person who borrowed the social security card into the medical insurance blacklist, and put Sun Four persons of a certain class were transferred to the public security organ for further verification.
It is worth noting that the formalism and bureaucracy of party members, leading cadres and public officials may also become factors for fraudulent insurance.
From January 2018 to September 2019, a hospital in Yanggu County, Shandong Province fraudulently obtained medical insurance funds through falsified medical records.
When the two cadres of the county medical security bureau reviewed the relevant hospitalization documents, they did not take them seriously, did not conduct in-depth investigations, and failed to discover the hospital's medical records fraud in time, which caused adverse effects.
In the end, the two were dealt with because they did not perform their duties in place.
3 The supervisory system is not sound, the departmental linkage needs to be strengthened, and further efforts are needed to combat fraud and insurance
In the “not forgetting the original heart, keeping in mind the mission” theme education special rectification of the problem of disregarding the interests of the people, the Central Commission for Discipline Inspection and the State Supervision Commission took the lead, and the National Medical Security Bureau, based on its functions and responsibilities, severely investigated and dealt with fraud and insurance fraud, and investigated and dealt with fraudulent insurance at designated points 154,000 medical institutions have recovered 5.97 billion yuan in medical insurance funds and liquidated damages.
"In 2020, the National Medical Insurance Bureau organized the supervision and inspection of 91 designated medical institutions, 56 handling institutions, and 40 commercial insurance institutions that deal with critical illness medical insurance in 31 provinces, autonomous regions, and municipalities and the Xinjiang Production and Construction Corps. The amount of suspected violations of designated medical institutions totals more than 500 million yuan." The head of the Fund Supervision Department of the National Medical Insurance Administration introduced.
Thanks to various efforts, the number of people participating in basic medical insurance nationwide will be 1.36 billion in 2020, with the participation rate stabilizing above 95%, and the number of people participating in maternity insurance will be 240 million, establishing the world's largest universal medical insurance network.
The income of the basic medical insurance fund was 2.4 trillion yuan, the expenditure was 2.1 trillion yuan, and the accumulated balance was 3 trillion yuan.
"However, some insured units, insured persons, medical institutions, medical personnel, industry authorities, regulatory agencies, and other multi-party games, the issue of collusion between multiple parties to defraud insurance cannot be ignored. Both parties or parties reach an agreement to form an offensive and defensive alliance. The problem of fraudulent insurance is more concealed.” According to Li Zhongmin, a teacher at the Southwest University of Political Science and Law School of Law, fraudulently obtaining medical insurance ultimately harms the vital interests of every insured person, which is essentially an illegal act.
According to the Legislative Interpretation of the Standing Committee of the National People’s Congress on fraudulent insurance, fraud, forged certification materials or other means to defraud social insurance funds or other social security benefits such as pension, medical care, work injury, unemployment, maternity, etc., belongs to the 260th Criminal Law The act of defrauding public and private property as stipulated in Article 16.
“There are many reasons why hospital fraudulent insurance is not stopped after repeated prohibitions. There are not only objective factors such as imperfect supervision system and imperfect restraint mechanism, but also the subjective understanding of the insured masses, medical insurance designated hospitals and designated pharmacies.” National Medical Insurance Administration The relevant person in charge of the Fund Supervision Department introduced that the medical insurance fund has a wide range of supervision points, covering many aspects such as medicine, law, and auditing. In addition, the legal basis for supervision is relatively weak, the profit-seeking motive of medical institutions still exists, and the linkage of departments needs to be strengthened. Medical insurance fraud cases will appear frequently.
4 Work together to build a full-field and full-process medical security fund security prevention and control mechanism
"We must resolutely investigate and punish the collusion between internal and external medical institutions to fraudulent insurance, and establish and strengthen a long-term monitoring mechanism." The Fourth Plenary of the 19th Central Commission for Discipline Inspection made requirements for the investigation and handling of fraudulent insurance and other issues.
The Fifth Plenary Session of the 19th Central Commission for Discipline Inspection made arrangements to continuously correct corruption and work style issues in the medical field.
In March last year, the Central Committee of the Communist Party of China and the State Council issued the "Opinions on Deepening the Reform of the Medical Security System", which clearly stated that the medical security fund is the "life-saving money" of the people and must always maintain the security of the fund as the primary task; on July 9, the State Council The General Office issued the "Guiding Opinions on Promoting the Reform of the Medical Security Fund Regulatory System", proposing to accelerate the reform of the medical insurance fund regulatory system and build a full-field and full-process fund security prevention and control mechanism; on December 9, the State Council executive meeting passed "Regulations on the Supervision and Management of the Use of Medical Security Funds (Draft)", the use and supervision of medical insurance funds will usher in high-standard special regulations...A series of measures aimed at ensuring the safety of medical insurance funds have been introduced to promote the medical security governance system and governance capabilities modernization.
While cracking down on fraud and insurance fraud and promoting the construction of relevant laws and regulations, medical insurance departments at all levels have actively cooperated with disciplinary inspection and supervision agencies, and have made positive progress in joint law enforcement, case transfer, and joint punishment.
The Disciplinary Inspection and Supervision Team of the National Supervisory Commission of the Central Commission for Discipline Inspection and the National Health Commission supervised and promoted the National Medical Insurance Bureau to implement the responsibility of medical insurance fund supervision and law enforcement, and the National Health Commission to implement the supervisory responsibility of industry authorities, forming a joint force to strengthen the supervision of medical insurance funds.
"Recently, in conjunction with the suspected fraud and insurance fraud cases in some designated medical institutions in Taihe County, our bureau and the National Health Commission have jointly organized a'look back' work on the special governance of designated medical institutions." The head of the Fund Supervision Department of the National Medical Insurance Administration introduced , Using the 45 days before the Spring Festival to focus on combating vicious fraud and insurance fraud of "fake patients" and "fake conditions", and resolutely prevent similar cases from happening again.
The Shanxi Provincial Commission for Discipline Inspection and the Provincial Medical Insurance Bureau jointly issued the "Working Measures on Handling Clues on Fraud and Insurance in Collusion between Medical Institutions and Outsiders", established a clue transfer mechanism for public officials involved in fraud and insurance, and jointly investigated clues in fraud and insurance cases, as of 2020 At the end of October, the province sent a total of 572 clues to the discipline inspection and supervision agencies; the Anhui Provincial Commission for Discipline Inspection and the Provincial Medical Insurance Bureau jointly formed a research and supervision team to go deep into some cities and counties medical insurance bureaus and designated medical institutions to investigate and supervise the special treatment of fraudulent insurance The progress of work and the improvement of the effectiveness of special governance; Huai'an City, Jiangsu Province has embedded the "Supervision by the Disciplinary Inspection Commission" module in the municipal medical insurance intelligent monitoring system to handle early warning issues at different levels, strengthen dynamic supervision and follow-up management.
2021 is the first year for the implementation of the "14th Five-Year Plan" and the start of a new journey of comprehensively building a modern socialist country.
"The medical insurance work must adhere to the general tone of seeking progress while maintaining stability, firmly grasp the theme of high-quality development of medical security, establish and improve a long-term mechanism for fund supervision, and constantly weave the medical insurance fund supervision system cage." The relevant person in charge of the National Medical Insurance Bureau Introduction.
(Our reporter Xue Peng)