Insufficient supervision capacity and penalties are weak Weak medical insurance fund fraud and fraud situation
Medical insurance fund supervision system cage must be tightly bound
Our reporter Du Xiao
Jin Yu
Not long ago, 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 proposed that we should organize tightly the system cage of medical insurance fund supervision, focus on promoting the reform of the regulatory system, and establish and improve the medical insurance credit management system. Strictly crack down on fraud and insurance, and ensure the safe, efficient and reasonable use of funds.
Hu Jinglin, secretary of the Party Leadership Group and director of the National Medical Security Administration, recently wrote that
The current serious situation of medical insurance fund fraud and fraud is on the one hand because structural reforms on the supply side of medical services are not in place, and medical institutions have a strong incentive to profit; on the other hand, it is also related to the long-term leniency and softness of fund supervision. The main reason is the lack of supervision system, insufficient supervision ability, and weak penalties. In recent years, the actions against fraud and fraud have formed a "tackling of the symptoms", and there is still a long way to go before they can cure the problem. We must be prepared for long-term and repeated struggles.
The medical insurance fund is the "life-saving money" of the people. For a long time, people hated the fraud of various medical insurance funds. "Legal Daily" reporter interviewed this.
Induced hospital exchange of drugs
Medicare fraud is common
Wang Hao (pseudonym), a doctor who once worked at a designated medical insurance hospital, has a certain understanding of the problem of doctors fusing medical insurance funds with patients.
According to Wang Hao, some doctors will borrow ID cards from relatives and friends, and sometimes higher-level departments will ask a doctor to collect a certain number of ID cards, because an ID card means a small amount of medical insurance funds.
Wang Hao told the reporter of the Legal Daily that after the identity card is available, follow-up diagnosis, prescription, and hospitalization are all handed over to the doctor for operation, all of which do not need to be present.
"Some people are not sick at all or have only a small problem. If they do not meet the standard of hospitalization, they write their medical records more seriously. If no disease is said to be a disease, a minor disease is said to be a serious disease. As long as they can be self-explanatory, their condition and prescription can pass the superior. Inspection by the department is sufficient. "Wang Hao said.
According to Wang Hao, when the acquaintance's ID card resources are used up, the doctor will turn to patients who have come to the clinic because of some headaches such as headache and brain heat. The doctor will tell them that if they are admitted to the hospital, the fees will be refunded when they are discharged. The medication during the hospitalization will be more than the reimbursement of the outpatient service, and the diet will be provided free of charge every day. Some patients will agree with the hospital's practice and go to the hospital for admission.
"The hospital is not afraid to be detected, but some doctors will still fake fake medical records driven by benefits. However, in recent years, the crackdown on medical insurance fraud has been increasing. This hospital's road to fraudulent insurance is difficult to maintain. Badly closed down. "Wang Hao said.
The reporter of "Legal System Daily" learned that as early as January 25, 2019, when the National Medical Insurance Bureau reported a typical case of fraudulently obtaining medical insurance funds, it included fraudulently obtaining medical insurance funds through false, induced hospitalization, and exchange of drugs.
According to the National Health Insurance Bureau's report, there were 207 suspected medical records of violations of regulations in the Central Hospital of Tulihe Township, Yakeshi City, Hulunbeier City, Inner Mongolia Autonomous Region. There were violations of agreement management such as over-checking, over-diagnosis, and over-medical treatment. Among them, 7 cases were falsely hospitalized from June 2016 to October 2017, involving 22,000 yuan in medical insurance funds. The medical insurance department recovered the medical insurance fund of 22,000 yuan and imposed a five-time fine of 110,000 yuan in accordance with relevant laws and regulations.
Wang Yue, a professor at the School of Medicine and Humanities of Peking University, told the reporter of the Legal Daily that the fraud of medical insurance seriously threatened the security of the medical insurance fund, and that the unreasonable use of the medical insurance fund caused no money to be used. Medical insurance funds are limited. Fraudulently obtaining medical insurance funds is a malicious encroachment on public resources, taking medical insurance funds that should not belong to them for their own use, and endangering the lives and health of those patients who really need them.
"Due to the existence of insurance fraud and the need to improve the level of medical insurance fund management in some hospitals, there is a problem of tightness before and after. It may take up to 10 months of medical insurance quota in the first 6 months, which makes patients see a doctor at the end of the year. At that time, the hospital would shove. "Wang Yue said.
Complex causes of health care fraud
Legal system needs to be improved
It is understood that after the establishment of the National Medical Insurance Bureau in 2018, it quickly organized a nationwide special operation to combat fraud and obtain medical insurance funds. During the operation, a total of 197,000 designated medical institutions and retail pharmacies were inspected, and 66,000 medical institutions that violated laws and regulations were investigated and punished. Of these, 1,284 medical insurance agreements were terminated, 127 were transferred to justice, and 24,000 illegal and illegal participants were investigated and punished.
Under the unified deployment of the Ministry of Public Security, public security organs across the country have also stepped up their crackdown on fraudulent use of medical insurance funds in recent years.
Wang Yue analyzed that an important reason for the repeated prohibition of medical insurance fraud is that the relevant legal system has not been perfected. At present, the penalties for medical insurance fraud cases, whether administrative penalties or criminal penalties, need to be further improved.
"On the administrative side, the relevant departments are actively promoting the formulation and implementation of the Regulations on the Use of Medical Insurance Funds, hoping to further strengthen administrative responsibilities; on the criminal side, there is still no corresponding crime for medical insurance fraud, and the crime of insurance fraud in criminal law is mainly for commercial insurance. It is not yet possible to cover this type of fraud against social insurance. Although the parties are sometimes held liable for the crime of fraud, in fact, the fraud in some hospitals is a collective behavior, a unit behavior, not a case, or even some private The legal representative of the hospital encouraged and coerced doctors to do it. "Wang Yue said.
Therefore, Wang Yue believes that it is possible to consider setting up a special crime of medical insurance fraud, which not only includes individuals but also units. "If it is an organized crime, it is necessary to investigate the relevant responsibilities of the legal representative of the medical institution. Only by further clarifying the corresponding legal responsibilities can we better deter and regulate such illegal acts."
It is worth noting that health insurance fraud may also include other purposes.
Professor Hu Jichen of China University of Political Science and Law said, "For example, in a family, the son is a publicly funded medical care, the mother is an urban and rural residents' insurance, and the two have different reimbursement benefits. In this case, there are two ways of reimbursement. When the two took the same medicine, the son would naturally prescribe more medicine to the mother. "
"Legal Daily" reporter interviewed some consumers at random outside the Medicare designated pharmacy and found that it is not uncommon to use their own Medicare card to buy medicine for their families.
"If strictly in accordance with the current regulations, this behavior is an illegal operation, but it is more common in real life. I think the deeper reason lies in the fragmentation of the medical insurance system." Hu Jichen said.
Hu Jizheng went to a certain place to conduct related research. There is a special company in the local area. The company does not have any business. The company was established for renal dialysis. Because renal dialysis is expensive, ordinary individuals need to pay for it at their own expense, but medical insurance can be reimbursed. Seven or eight patients set up this company specifically to be able to enjoy medical insurance, not to make money, but to save money.
"There are still some shortcomings in the current medical insurance policy. Some patients in real need cannot enjoy the benefits brought by medical insurance for various reasons, while others can easily use the loopholes in the policy to obtain benefits. No one wants to get sick. After getting sick, you need to spend money on treatment. Sickness, from the perspective of humanistic care, we should pay more attention to socially disadvantaged groups and not let them be the objects of forgetting. "Hu Jichen said.
Continuously improve the decision-making mechanism
Bring the root cause to the people
The Opinions on Deepening the Reform of the Medical Security System states that strengthening the supervision capacity building of medical insurance funds and further improving the fund supervision system and mechanism. Implement inter-departmental coordinated supervision, actively introduce third-party supervision forces, and strengthen social supervision. Establish a normal mechanism for supervision and inspection, and implement real-time dynamic intelligent monitoring of big data. Improve the monitoring mechanism for medical services, establish a mandatory information disclosure system, and disclose medical expenses, fee structure and other information to the society in accordance with laws and regulations. Formulate and improve laws and regulations related to the supervision of medical insurance funds, standardize regulatory authority, procedures, and punishment standards, and promote law-based administration. Establish a medical security credit system and implement joint incentives for trustworthiness and joint punishment for breach of trust.
At the beginning of January this year, the Huzhou Medical Security Bureau of Zhejiang Province was approved to establish the country's first "Medical Security Anti-Fraud Center", which will assume the functions of supervision and inspection of medical insurance funds.
"I hope to innovate the supervision method of medical insurance funds, set up a medical insurance anti-fraud center, conduct substantive operations, and solve the problem of weak supervision." Said Yu Wenwei, director of the fund supervision department of Huzhou Medical Security Bureau.
The information from the official website of the Huzhou Municipal People's Government indicates that the medical insurance department will further integrate multi-sectoral forces such as medical insurance, health, market supervision, and public inspection law, improve the joint supervision mechanism, and truly form a supervision pattern of inter-department information exchange, mutual recognition of results, and superimposed power .
In Wang Yue's opinion, the current medical insurance policy needs to further improve the communication mechanism with medical institutions. If the medical insurance policy is not formulated properly, medical institutions and medical staff will have to use some methods to bypass related policies, which will eventually lead to the phenomenon of "upper policies and lower countermeasures" in the implementation process.
In order to fundamentally solve the problem of medical insurance fraud, Wang Yue believes that, first of all, to free medical institutions from the state of profit-seeking, medical staff cannot consider making money every day. Secondly, establish a fee control reward mechanism. If the cost control is good, the operation is difficult, and the patient satisfaction is high, you can use the medical insurance fund to give some rewards to the medical staff, which is equivalent to using the medical insurance fund to subsidize medical institutions.
"If the medical insurance fund is used well, it can greatly improve the people's health and happiness index; if it is not used well, it will cause waste of resources." Wang Yue said, "The rational use of medical insurance funds requires a more scientific and democratic decision-making mechanism. The so-called Science means that decision-making should be based on data. In the future, big data and other technologies can be used to manage medical insurance funds; so-called democracy refers to public participation, including individuals or organizations representing patients' interests, and experts and scholars in various fields. "