Insurance fraud incident in Tongji Hospital: Difficulties in the supervision of medical insurance funds
China News Weekly reporter / Zhang Xinyu
Published in the 1043rd issue of "China News Weekly" on May 16, 2022
"In the past, we have always been proud and proud of being Tongji people. The incident reported in April made our older generation feel very embarrassed and sad." Tongji Hospital Affiliated to Tongji Medical College of Huazhong University of Science and Technology (hereinafter referred to as "Tongji Hospital") ”) Chief physician Cui Zhen, who has been retired for several years, felt very unbelievable when he learned that Wuhan Tongji Hospital was associated with “defrauding insurance”.
On April 20, the National Medical Insurance Administration announced a report on the special unannounced inspection of Tongji Hospital. The report showed that from January 2017 to September 2020, Tongji Hospital had the problem of collusion and false records of high-value orthopaedic medical consumables, and fraudulently obtained medical insurance. The fund paid more than 23.34 million yuan.
Wuhan Medical Insurance Bureau fined Wuhan Tongji Hospital a total of more than 59.24 million yuan, ordered the hospital to suspend medical services involving the use of medical insurance in the Orthopedics Department for 8 months, and transferred it to relevant departments such as public security, market supervision, drug supervision, health and discipline inspection and supervision in accordance with laws and regulations clues to the case.
According to the report, the unannounced inspection also found that Tongji Hospital was suspected of illegally using 91.0741 million yuan of medical insurance funds in other medical behaviors in 2021, which is still being further verified and processed.
Relevant staff of the National Medical Insurance Administration told China News Weekly that there is no more information to disclose at this stage, and will be notified after the inspection is over.
A number of interviewed doctors were shocked that the fraudulent insurance was exposed to a well-known tertiary hospital in the country, and they were also surprised by the huge amount of fraudulent insurance.
A person familiar with the matter told China News Weekly that a few years ago, a public hospital had defrauded the medical insurance fund to reach a higher amount, but it was not notified at that time.
The frequent occurrence of insurance fraud in public hospitals reflects the difficulties in the supervision of medical insurance funds, and solving hospital insurance fraud is a worldwide problem.
"Always worried about orthopaedic accidents"
Tongji Hospital was founded in Shanghai in 1900 by German doctor Erich Baolong, and became a modern hospital in China in the 1930s and 1940s. Not only has it been well received in Shanghai and the Yangtze River Basin, but it has also attracted the attention of all classes in China.”
In 1955, under the background of backward medical and health conditions and lack of medical talents in the central and southern regions, Tongji Hospital moved to Wuhan.
At present, Tongji Hospital, as a large public hospital under the management of the National Health Commission, has 8 national key disciplines and 30 national key clinical specialties.
In the "2020 Comprehensive Ranking of Chinese Hospitals" released by the Institute of Hospital Management of Fudan University, Tongji Hospital ranks sixth in the country's comprehensive hospital rankings.
"In Hubei Province, we believe that Tongji Hospital is the leader and has a benchmark position." Qin Wen, director of the emergency department of a tertiary hospital in Wuhan, believes that Tongji Hospital's illegal use of medical insurance funds may be related to its late entry into medical insurance.
Tongji Hospital was only covered by Wuhan Municipal Medical Insurance in 2013. At first, only Cardiac and Great Vascular Surgery was covered by medical insurance. Until January 2021, all departments of Tongji Hospital were covered by Wuhan Municipal Medical Insurance.
According to a report in Chutian Golden News in January 2013, Xia Jun, director of the Medical Insurance Office of Tongji Hospital, said at the time that the major reason why the Cardiac and Great Vascular Surgery was the first to join Wuhan’s medical insurance was mainly because the major cardiovascular surgeries were basically difficult and critical. For major surgery, patients expect to be covered by health insurance while undergoing surgery.
The Cardiovascular Surgery Department of Tongji Hospital also found that through reasonable management and control of medical costs, it was possible to evenly spread the cost of receiving medical insurance patients without losing money. Therefore, the department decided to take the lead in entering medical insurance.
The report shows that the reason why the National Medical Insurance Bureau will conduct unannounced inspections of Tongji Hospital is because it has received reports.
Unannounced inspections refer to unannounced on-site inspections conducted by the medical insurance management department on designated medical institutions.
Many respondents, including Cui Zhen, speculated that the whistleblower was a consumable supplier who had cooperated with Tongji Hospital Orthopaedic Department.
"Orthopedics and consumables suppliers are in the same chain of interests. Originally, we were not very used to orthopedics. Their orthopedic consumables did not go through the equipment department of the hospital. What should the orthopedic doctor use? Businesses deliver things to the door of the operating room. Orthopedic consumables are highly profitable, and orthopedic doctors are easy to become upstarts." Cui Zhen said that in Tongji Hospital, the orthopedics department is privileged, "We are always worried that there will be an accident in the orthopedic department."
This time, Tongji Hospital defrauded the medical insurance fund by exchanging and falsely remembering high-value orthopedic medical consumables.
Qin Wen, who has been researching the type of hospital insurance fraud in the past two years, said that each medical consumable has a separate pricing code, and the hospital scans the code for billing. The pricing code of B consumables, the high-priced consumables are finally paid by the patient, and the medical insurance will pay the bulk.
A doctor who had previously reported fraudulent hospital insurance believes that such violations are very subtle.
In the insurance fraud case of Zhengzhou No. 6 Hospital in 2021, a doctor in the hospital publicly reported that the director of the orthopaedic department replaced the high-value minimally invasive screws with low-value implants into the patient's body.
The whistleblower doctor told the media at the time that the patients and their families did not know professional medical consumables, and other doctors often did not pay attention to this detail during the postoperative review, so the "sleeve labeling" behavior was not easy to detect.
"This kind of violation is very difficult for the staff of the Medical Insurance Bureau to detect. Generally, someone needs to report it, and only people who know the business and know the inside story can report it." Qin Wen said.
Cui Zhen believes that if the matter of Tongji Hospital's illegal settlement of medical insurance funds is not reported by insiders, "the tumor will continue to expand."
Sun Hongtao, chief physician of the Department of Cardiac Surgery of Fuwai Hospital, Chinese Academy of Medical Sciences, told China News Weekly that more departments using high-value medical consumables are more cost-effective to cheat insurance. For steel nails, the income will be more, otherwise you can only record a few more pieces of gauze, which is of little significance.” But Sun Hongtao also said that this does not mean that departments that use high-value medical consumables are easy to cheat insurance, as long as they are careful, some do not use high-value medical consumables. Small hospitals that value medical consumables can also cheat insurance.
Public hospital insurance fraud methods are more hidden
Before and after the establishment of the National Medical Insurance Bureau on May 31, 2018, the supervision of medical insurance funds has faced a particularly severe situation.
Cai Haiqing, the former director of the Treatment and Guarantee Division of the Jiangxi Provincial Medical Insurance Bureau, told China News Weekly that from what was known at the time, the phenomenon of obtaining medical insurance funds through violations of laws, regulations and breaches of contract was not whether there was or not, but more and less harmony. Big and small problems, all kinds of means to renovate, and strange tricks occur frequently - decomposition charges, super-standard charges, repeated charges, applied item charges, hanging bed hospitalization, repeated hospitalization, outpatient transfer to hospital, exchange of medicines and consumables , diagnosis and treatment items, fictitious medical services, forging medical documents and bills, stealing social security cards, forging false bills for reimbursement, impersonating doctors, using social security cards to obtain medicines, repurchasing and reselling, and so on.
Deng Mingpan, a partner of Sichuan Runze Law Firm, mainly studies the field of health and health law. According to his research, there are usually some differences in the methods of insurance fraud in private hospitals and public hospitals. Lowering the standard of hospitalization, falsifying medical documents and medical records, fictitious diagnosis and other methods to defraud insurance, and these methods of insurance fraud often appear together.
Sun Hongtao, Chief Physician of Cardiac Surgery, Fuwai Hospital, Chinese Academy of Medical Sciences believes that for private hospitals, it is difficult to survive without patients, and medical insurance is the lifeline. crooked way".
The insurance fraud incident of two private hospitals in Shenyang that attracted national attention in 2018 is a typical case of hanging bed and hospitalization. At that time, it was revealed that Jihua Hospital in Yuhong District, Shenyang used an intermediary to lure patients with medical insurance cards to the hospital for hospitalization, and the hospital forged the patients. Medical records and prescriptions were issued, but no medication was actually given to the patient or no treatment was given. Shenyang Friendship Nephropathy Traditional Chinese Medicine Hospital was exposed to recruit fake patients outside the hospital through the head of the information department of the hospital, conduct fake treatment, and defraud the national medical insurance fund.
Fake patients usually get cash commissions or gifts from the hospital after they are hospitalized.
Deng Mingpan said that compared with private hospitals, the way of fraudulent insurance in public hospitals is more concealed, because "the internal management of public hospitals is relatively standardized, the functional departments are relatively sound, and they also face regular annual financial audits." The medical insurance violations of public hospitals are mainly manifested in excessive Inspection, over-diagnosis, exchange of high-value medical consumables, etc.
In practice, it is more difficult to define over-examination and over-diagnosis.
The "Civil Code of the People's Republic of China Study Book" edited by the Civil Law Office of the Legislative Affairs Committee of the Standing Committee of the National People's Congress mentioned that the medical industry has its own particularities, which are mainly reflected in the uncertainty of diseases and the diversity of diagnosis and treatment measures, which also leads to the practice of It is difficult to have a clear boundary between moderate inspection and excessive inspection, and its identification is a very professional issue that needs to be confirmed through professional appraisal.
Only when a medical institution clearly violates its statutory obligations and deviates from the requirements of appropriate examinations, resulting in a significant excess of examinations, can it be considered as excessive examinations.
A staff member who was responsible for handling disputes between doctors and patients in a tertiary hospital in Wuhan believed that in some cases, what patients think of as excessive examinations is actually the self-protection of doctors, not only because doctors have enough examination results to make a diagnosis. , but also because the burden of proof of medical disputes is mostly borne by medical institutions, and doctors will do as many inspections as possible in the diagnosis and treatment as evidence.
Chen Qiulin, deputy director of the Health Industry Development Research Center of the Chinese Academy of Social Sciences, said that hospital insurance fraud across the country has generally improved.
Since the establishment of the National Medical Insurance Bureau, it has carried out a special rectification campaign against fraudulent insurance for five consecutive years. According to the data of the National Medical Insurance Bureau, from 2018 to October 2021, a total of about 2.34 million designated medical institutions were inspected nationwide, and about 1 million were processed. Second, the cumulative recovery of medical insurance funds is about 50.6 billion yuan.
In 2021 alone, the National Medical Insurance Bureau recovered 23.418 billion yuan of medical insurance funds, organized 30 groups of unannounced inspections, and actually inspected 68 designated medical institutions and 30 medical insurance agencies in 29 provinces.
In the article "Medical Insurance Violation Cases and Response Suggestions" published by the magazine "China Hospital President" in December 2021, Deng Mingpan sorted out the medical insurance illegal settlement or fraudulent insurance cases of medical institutions disclosed by the National Medical Insurance Bureau in 2021, and found that they were ranked in the medical insurance The top three violation cases are unreasonable or illegal charging behavior, excessive inspection and diagnosis and treatment, and exchange of medicines and medical consumables. The behavior of hanging bed hospitalization, dismantling hospitalization, impersonating hospitalization or swiping medical insurance cards has decreased compared with 2018.
Deng Mingpan believes that this shows that the crackdown on illegal settlement of medical insurance or fraudulent insurance is effective.
The income-generating pressure behind fraudulent insurance
There are multiple reasons behind the frequent occurrence of insurance fraud in public hospitals.
Cai Haiqing, former director of the Treatment and Security Division of the Jiangxi Provincial Medical Insurance Bureau, believes that medical institutions, as providers of medical services, should adjust their medical service behaviors according to different settlement methods of medical expenses within the scope permitted by the policy, in order to obtain more shares of medical insurance. Funds are an unreasonable rational behavior. The problem is to grasp the "degree".
"For medical institutions and their medical staff, if they do not understand and are not familiar with the medical insurance policy, coupled with the lack of strict and resolute implementation of the policy, and even the psychological rejection or even opposition to the medical insurance policy, it is easy to happen. Violating the provisions of the medical insurance policy, or even maliciously defrauding insurance." Cai Haiqing said.
As for the root cause of hospitals defrauding medical insurance funds, Li Ling, a professor at the National Development Institute of Peking University, believes that it is still the pressure of hospitals to generate income, "This involves the interests of the hospital, the interests of the departments, and the interests of each doctor, and this is a matter of course. from the health insurance system.”
Cai Haiqing said that although the state has repeatedly emphasized in many policy documents that medical institutions "are strictly prohibited from issuing income-generating indicators to departments and medical staff, and medical staff's salaries must not be linked to business income such as drugs, health materials, inspections, and laboratory tests," but from the actual situation, Cai Haiqing said. From the point of view, the personal income of medical staff is still linked to the income generated by the hospital.
In Chen Qiulin's view, the reason why hospital insurance fraud has existed for a long time is not only that the hospital itself has motives, but the mechanism of medical insurance also determines that medical institutions have the opportunity to defraud insurance.
Chen Qiulin likened hospitals and patients to car 4S shops and car owners, and compared seeing a doctor to car repairs. "In the case of insurance, 4S shops and car owners are motivated to spend more to repair cars. Anyway, insurance companies reimburse." Chen Qiulin believes that , Under the existing medical insurance system, once the hospital has a profit-seeking mechanism and has to rely on its own money to develop, it is difficult to prevent fraudulent insurance.
Chen Qiulin added that there is another objective situation that needs to be considered, "In the past few years, the medical reform 'vacating the cage and changing the bird' is to increase the price of medical services and reduce the cost of medicines, so the hospital needs to digest part of it and the government subsidizes part. In fact The cost of medicines has been cut down, but have the prices of medical services increased? Are government subsidies in place? If some places are not in place, how can hospitals make up for the reduced income? In the past few years, some large public hospitals did not operate well. Something went wrong. We also had a lot of meetings on how to 'fuel' the public hospitals."
From an orthopedic surgery, it may be possible to see the shortage of doctors' sunshine income.
An article in "China Health Economy" in December 2020 showed that from 2014 to 2018, among the per capita hospitalization expenses paid by patients undergoing artificial joint replacement in a tertiary hospital in Guangzhou, the proportion of consumables expenses reached 55.63%, which was 39,350.66 yuan, while surgery The cost composition ratio is only 3.31%, which is 2341.07 yuan, and the total cost of other service items is 7194.13 yuan.
Low operation fees and service fees mean that doctors can get less sunshine income from operations, and more hidden income from rebates on consumables.
From gaming to collaboration
In May 2021, the "Regulations on the Supervision and Administration of the Use of Medical Insurance Funds" (hereinafter referred to as the "Regulations") were officially implemented. As the first special administrative regulation in the field of medical insurance in China, it is regarded as the beginning of the legalization of the management of medical insurance funds in China. important sign of the track.
Cai Haiqing, who has many years of front-line work experience, believes that one of the difficulties in combating hospital insurance fraud is that the legal system construction and standardization in the medical security field are relatively lagging behind. After the "Regulations" are promulgated, the urgent task is to fully, accurately and strictly implement the "Regulations".
Just one regulation is not enough.
Zheng Gongcheng, president of the Chinese Society for Social Security and professor of Renmin University of China, proposed medical security legislation at the National People's Congress in 2019 and 2020, and participated in the drafting of the "Medical Security Law" (drafted by experts). He once said that medical security is the whole The only major institutional arrangement in the social security system that covers the entire population, involves the most complex relationships, and has the longest business chain. It is not only an inherent requirement of this system, but also an internationally accepted practice to formulate and implement it in accordance with the law. Since the establishment of the Medical Insurance Law in Germany in 1883 . From the perspective of Japan's first social security law, namely the Medical Insurance Law, the medical security system has higher legal requirements than other systems.
China may not be far from having a Medical Insurance Law.
On June 17, 2021, the official website of the National Medical Insurance Administration issued an announcement to formally solicit public opinions on the "Medical Security Law (Draft for Comment)".
On May 6, 2022, the Standing Committee of the National People's Congress announced the "2022 Legislative Work Plan of the Standing Committee of the National People's Congress", and the items to be reviewed include the "Medical Security Law".
Under the existing "Regulations", Cai Haiqing believes that the "double random, one open" medical insurance fund supervision mechanism should be fully implemented, and a multi-form inspection system combining daily inspections, special inspections, unannounced inspections, key inspections, and expert reviews should be established and improved. .
Cai Haiqing also suggested to comprehensively establish and continuously improve the medical insurance intelligent monitoring system, strengthen the application of big data, strengthen the supervision before and during the event, and improve the intelligent monitoring function.
In addition, in the case that many insurance frauds are relatively concealed and rely on insiders to report, Cai Haiqing also suggested improving the reporting reward system to encourage and support all sectors of society to participate in the supervision of medical insurance funds.
Taking Hubei Province as an example, the "Implementation Rules for Reporting Rewards for Fraudulently Obtaining Medical Security Funds in Hubei Province (Implementation)" formulated in September 2019 proposed that medical security administrative departments at all levels will reward 2% of the verified amount, with the highest individual reward amount. not more than 100,000 yuan.
Li Ling, a professor at the National Development Institute of Peking University, said that the DRG/DIP medical insurance payment method promoted by the National Medical Insurance Administration is also a powerful weapon to combat hospital insurance fraud, especially excessive medical treatment.
In the past, medical insurance was paid according to traditional items. According to the total amount of each item multiplied by the unit price, it was paid to the hospital according to the reimbursement ratio.
DRG payment, on the other hand, divides patients into diagnosis-related groups with similar clinical symptoms and resource consumption according to factors such as the type of patient’s disease, severity of disease, and treatment methods, and no longer pays according to the patient’s service items, and guides hospitals to reduce unnecessary Treatment and service items have achieved the purpose of optimizing medical resources and controlling medical insurance costs. Even so, countries have used the DRGs method for nearly 40 years, with little success.
DIP is an advanced payment method based on big data invented by the Chinese. It combines points method, total budget, payment by disease points, etc., in order to expand the coverage of diseases and effectively control fund risks.
Ying Yazhen, vice president of the National Medical Insurance Research Institute and vice president of the China Medical Insurance Research Association, said earlier that the implementation of DRG/DIP payment will effectively change the long-term disadvantages of passive payment of medical insurance, extensive development of hospitals, and heavy burden of patients seeing a doctor. For the three parties, it is a mutually beneficial and win-win reform.
In 2021, there are 30 DRG pilot cities across the country, and 71 cities have launched DIP payment pilots.
According to the "Three-Year Action Plan for the Reform of DRG/DIP Payment Method" issued by the National Medical Security Administration at the end of November 2021, by the end of 2025, the DRG/DIP payment method will cover all qualified medical institutions that provide inpatient services, and basically achieve disease types, The medical insurance fund is fully covered.
However, in Li Ling's view, even if the reform of the medical insurance payment method is more refined, the weapon against hospital insurance fraud has only been changed from broadswords and spears to foreign guns and foreign guns, and the hospital can always find a way to deal with it.
"How to solve insurance fraud is a worldwide problem. Even in Germany, which had medical insurance in the 19th century and a very high level of supervision, all available methods to combat insurance fraud, including DRGs, were used, but the problem of medical insurance abuse still could not be controlled. "Li Ling said.
Chen Qiulin said that the direction of future reforms is whether medical insurance can pay for the health of the public and for behaviors that promote health, not when the public is getting healthier, and hospitals have no income. This is the direction of exploration.”
(Cui Zhen and Qin Wen are pseudonyms in the text)
"China News Weekly" 2022 Issue 17
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