The medical insurance fund is the "life-saving money" of the masses, but many people regard this money as "Tang monk meat."

Some are made out of nothing, and they can make up "shadow patients" with only a medical insurance card; some use "condition magnifying glass" to fake patients who did not meet the hospitalization standards into surgical patients in batches; some incarnate "accounting masters" , The non-profit medical service has been completely made into a fake "business"... The reporter from Banyue Tan sorted out typical cases of fraudulent insurance and found out that the "three fakes" focusing on "fake patients, fake medical conditions, and fake bills" "Insurance fraud is detrimental to the interests of every insured person, and it is especially worthy of attention. It must be "targeted therapy".

1

"Shadow patient": All but the medical insurance card is fake

  The key to fraudulent insurance is fraud.

Some people can construct a "shadow patient" with complete hospitalization materials, signatures and other information with just one medical insurance card, and get medical insurance funds out of thin air.

  In the first phase of the Liaoning Jinjing Hospital's fraudulent insurance case exposed by the National Medical Insurance Bureau in 2021, the hospital director Huang Moumou and many people inside and outside the hospital borrowed a large number of insured medical insurance cards and swiped the cards in the Jinjing Hospital medical insurance system for false hospitalizations. , Made false medical records and false expense accounts and other materials, defrauding medical insurance funds of more than 2.9 million yuan in total.

  "Shadow patients" are fake except for the medical insurance card, and the cost is not high.

In the case of fraudulent insurance by Jinjing Hospital, the hospital only needs to pay a benefit fee of 100 yuan or 200 yuan for borrowing a medical insurance card.

In order to obtain the benefits, the teachers of a local teacher training school found relevant academic staff in many elementary schools, borrowed a large number of student medical insurance cards from the pupils in the school, and provided them to the hospital for fraudulent expenses.

  Fictitious "shadow patients" using the medical insurance cards of the insured persons can easily become key targets for the urban and rural grassroots and elderly groups.

A staff member of the Medical Insurance Bureau of a certain city in central China told Banyuetan reporters that some village-level designated organizations often take advantage of the masses’ unfamiliarity with medical insurance policies to collect medical insurance cards of insured persons to set up medical insurance funds, so that from the medical insurance information system, they will Found that "the whole village is sick".

  Because it is out of nothing, fictitious "shadow patients" often require multiple people to participate in the whole process of fraud.

In an insurance fraud case, the person in charge of the hospital requested the various departments of the hospital to coordinate and cooperate with each other in such aspects as pulling fake patients into hospital, emptying patients, idling drugs, and controlling the amount of medical insurance claims.

The insured people recruited by the salesman left after completing the free physical examination, but the "diagnosis and treatment" for the empty patients is still continuing. The doctors give orders and charges for the empty patients, and the nurse executes the false medical orders... The whole operation is comparable to an assembly line.

2

"Sickness magnifying glass": mass production of surgical patients

  Some patients are real, but the condition is fake.

Such fraudulent insurance mainly magnifies the condition through false diagnosis, falsifying patients who did not meet the medical insurance reimbursement threshold into surgery or critically ill patients that can collect more expenses.

Whether a patient needs to be hospitalized depends on whether the patient is an insured person or not, and whether the patient can be discharged depends on whether the cost is sufficient.

  In July 2020, the Intermediate People's Court of Ganzhou City, Jiangxi Province made a final judgment. Seven staff members of Ma'anshan Hospital in Jiading Town, Xinfeng County were sentenced for defrauding insurance, causing concern.

The Banyuetan reporter's investigation found that this non-profit medical institution approved by the local health department in 2011 was managed and operated at a cost of 230,000 yuan per year shortly after its establishment. The low-cost investment in return was more than one million yuan within a year. High returns for fraud.

  In order to facilitate the operation, this hospital specially designed a fraud insurance template.

According to the local medical insurance staff, after the patients whose fictitious condition meets the admission criteria are assigned to the inpatient department, the management doctor compares the pre-designed treatment project template and writes the corresponding false admission, disease course, inspection, surgery, medication and other records, making false records. In the medical records, a patient who did not need to be hospitalized is transformed into a surgical patient in the medical insurance system.

  "Fake medical conditions" fraudulent insurance fraud behaviors often occur in grassroots designated institutions with insufficient disease sources.

An expert engaged in medical insurance auditing revealed that designated institutions defrauded the medical insurance fund by lowering the hospitalization standard to admit patients and fictitious inpatient conditions, and the defrauded expenses were allocated according to a certain ratio between doctors and patients.

Under this specific interest alliance, it is often difficult to verify evidence for fraudulent insurance of "fake medical conditions", and it is even more difficult to combat investigations.

3

"Master of Accounts": There must be evidence for fraud

  Whether it is a "fake patient" or a "fake illness", the key to the final cost collection is to manipulate the bills. Through the fraudulent bills, the diagnosis and treatment items that did not actually occur, the unused medicines and consumables, etc., become plausible. according to.

  "Fake patients" and "fake conditions" mean that the corresponding drugs and consumables are not actually used in the diagnosis and treatment. The problem of the invoicing, sales and storage of drugs and consumables caused by this is a common manifestation of the fraudulent behavior of "fake bills".

The supervision department's unannounced inspection of a tertiary A hospital in western China found that the number of purchases of corresponding medicines in the hospital exceeded the number of outgoing medicines from the batch of medical suppliers.

An expert involved in the inspection said the tricks behind it: In order to avoid inspections, designated agencies often take out the medicines and consumables returned to the pharmacy from various departments but do not actually use them, and re-purchase them in the name of false purchases.

  The offsetting of purchase invoices has become an important link in the completion of false purchases.

In August 2020, the Guangdong Provincial Higher People's Hospital made a final ruling on the case of a friendly hospital defrauding medical insurance funds.

The court found that by recovering the cost of falsely prescribing medications in various departments and buying fake invoices and falsified drug purchase costs, the hospital had falsely declared drug reimbursements to the medical insurance department for a total of more than 130 million yuan.

In this process, the hospital spent more than 8.81 million yuan to purchase fake invoices.

  The National Medical Insurance Administration has carried out special treatments against fraudulent insurance for three consecutive years.

In 2020 alone, there were 401,000 medical institutions nationwide that dealt with violations of laws and regulations, and 22.31 billion yuan of medical insurance funds were recovered.

On May 1, my country’s first administrative regulation in the field of medical security, "Regulations on the Supervision and Administration of the Use of Medical Security Funds," was formally implemented, clearly delineating the untouchable red line for the people’s "medical money", and the multi-party system design is expected to be further strengthened. Supervise the cage to ensure that the limited funds are used on the cutting edge.

  Wang Zhen, director of the Public Economics Research Office of the Chinese Academy of Social Sciences, believes that while continuing to combat high pressures and recovering the stolen medical insurance funds, we must also strive to build a regulatory system that combines administrative supervision, social supervision, and industry self-discipline. .