Some medical institutions have over-medical treatment and even fraudulent insurance, which makes the medical insurance fund a great waste
To protect the people’s “life-saving money” requires comprehensive law enforcement by multiple departments
[Talk about health]
The medical insurance fund is the common people’s money for medical treatment, and it is also “life-saving money”. However, some hospitals have over-medical treatment, which seriously wastes the medical insurance fund. What's more, some medical institutions even cooperated with medical staff to make frauds and obtain medical insurance. As long as you have a medical insurance card, you can check, prescribe medications, and even be hospitalized at will. If things go on like this, the medical insurance funds in some regions will "cross the bottom", which will not only seriously damage national interests, but also prevent patients who really need them from getting the protection they deserve.
The Fifth Plenary Session of the 19th Central Committee of the Communist Party of China put forward the goals of "a more complete multi-level social security system and a more complete health system" and "a new improvement in the effectiveness of national governance".
In order to achieve these goals, my country's medical security department and related departments need to manage and use the medical insurance fund to ensure the safety of my country's medical insurance fund and promote its effective use.
It is undeniable that in the process of using the medical insurance fund, multiple law enforcement agencies including medical security, health, traditional Chinese medicine, market supervision and management, civil affairs, finance, auditing, and public security all have certain supervision and management rights in accordance with the law.
In the past law enforcement practice, these departments mostly carried out supervision and law enforcement in their own way, and failed to coordinate with each other, which would lead to multiple, multi-layer law enforcement, duplicate law enforcement and other law enforcement conflicts.
These problems not only increase the burden of regulated pharmaceutical companies and medical institutions, and are not conducive to the optimization of my country's overall business environment, but also affect the fairness and efficiency of law enforcement in the medical security field, and it is difficult to efficiently implement the rule of law with limited law enforcement resources. The goal.
From another perspective, public health funds, civil affairs medical aid funds, and medical security funds are all "life-saving money" for the people. Ensuring the safe and effective use of these funds through comprehensive law enforcement means is not only a major livelihood issue, but also a major issue. Political mission.
Why multi-department comprehensive law enforcement is required for the supervision of the use of medical security funds
At present, my country has implemented comprehensive administrative law enforcement reforms in urban management, market supervision, ecological environment protection, transportation, agriculture, and cultural market management, breaking the fragmentation, and opening up regulatory links such as access, production, circulation, and consumption. Establish and improve multi-department, cross-regional law enforcement linkage response and coordination mechanisms.
An important reason for the multi-sectoral comprehensive law enforcement reform in these areas is to solve the problems of multiple law enforcement, multi-level law enforcement, and repeated law enforcement and law enforcement harassment.
In addition to the above reasons, the author believes that there are three specific reasons for the urgent need for comprehensive law enforcement by multiple departments in the use of medical security funds:
First, the price and quality of medical services based on the payment and use of the medical security fund are interrelated and affected, but they belong to the law enforcement functions of multiple different regulatory agencies. It is difficult for a single department to implement the law to achieve the goal of safe and effective use of the medical security fund. .
Among the above-mentioned medical services, the supervision department of medical service quality is the health administrative department, and the supervision of drug quality is the market supervision and management department, while the supervision and management department of medical service prices and drug prices belongs to the national price department and the medical security administrative department. .
When judging whether to fund a medical service, the medical security administrative department and the handling agency must ensure that the quality of the service has met the legal requirements, and judging whether the legal quality requirements are met and the corresponding law enforcement often belong to the health administrative department and The functions of the market supervision and management department.
This can explain on the one hand that the use of medical security funds urgently requires comprehensive law enforcement by multiple departments.
Second, for behaviors that violate the supervision and regulation of the medical security fund, three different law enforcement methods can be adopted in accordance with the law, namely the agreement management breach accountability mechanism, the administrative penalty mechanism, and the criminal penalty mechanism. These three law enforcement mechanisms operated by different departments or agencies need to be coordinated. Use to achieve maximum legal compliance with the least social cost.
The accountability mechanism for contract management breach is mainly operated by the medical insurance agency, and the designated medical institution that violates the medical insurance service agreement is held accountable for breach of contract.
The administrative punishment mechanism and the criminal punishment mechanism are initiated by the medical security administrative department and the public security organs, and they are mainly selected and applied according to whether the specific illegal act has constituted a crime; the criminal punishment mechanism should be applied to the act that constitutes a crime.
Different from the administrative penalty mechanism, the goal of the accountability mechanism for contract management breach of contract is mainly compensatory, that is, to quickly recover fund losses.
The lack of or less procedural requirements or control features of the agreement management default accountability mechanism leads to lower operating costs, and it is also conducive to quickly recovering fund losses through the mechanism.
However, its feature of less procedural control may also lead to a relatively high error rate in the decision to pursue liability for breach of contract through the agreement management breach of contract liability mechanism.
The unfavorable sanctions that affect the rights and interests of the insured persons to obtain timely medical services, and affect the personality rights of designated medical institutions and physicians shall be handed over to the medical security administrative department and other departments to make a decision through the corresponding administrative penalty procedures.
In addition, the use of criminal penalties requires more procedural control and more operating costs than administrative penalties. Therefore, in theory, criminal penalties should be used when the administrative penalties cannot sufficiently deter the offenders.
Third, the non-profit and state-owned nature of most medical institutions has led to some effective financial management systems such as invoice management that do not need to be followed or not strictly followed in the use of medical security funds, such as finance, auditing and other relevant authorities Supervision to ensure compliance with these financial systems or alternative systems will help medical security departments and medical insurance agencies to effectively supervise the use of medical security funds at a lower cost.
However, it has been found in practice that the supervision of the financial system of medical institutions is often absent.
The annual compliance audit reports of many medical institutions are basically a formality. There is no relevant audit unit, and some medical institutions do not even know which department these audit reports should be submitted to.
There are also some medical institutions that transfer the funds of the unit to other related units or even take it for themselves through long-term current account posting, cash payment, and blank entry. This will directly cause the loss of funds that should belong to the public health fund and affect Improved the service level of medical institutions.
In addition, the convenience of the aforementioned illegal possession has become an important incentive for fraudulent insurance.
It can be seen that the finance, audit, civil affairs, health, traditional Chinese medicine, and medical security departments check the relevant financial account data and inform each other of the relevant information when performing their supervisory duties, which not only enables the law enforcement inspections of various departments It is more efficient and can effectively promote more medical institutions to comply with relevant laws.
The specific approach of multi-department comprehensive law enforcement
Comprehensive law enforcement can reduce the cost and burden of law enforcement inspections on legitimate enterprises, and can also improve law enforcement efficiency, and improve compliance with relevant laws with minimal social costs.
In theory, comprehensive law enforcement can adopt the following two methods:
One is to consolidate the functions of most law enforcement agencies that meet the requirements for merger into a single agency, which can maintain the internal specialized departments of a single agency, but as a whole it belongs to the unified management of the single agency, referred to as the "merger" method. .
The aforementioned merger condition can be expressed as "If the functions of multiple law enforcement agencies are to deal with the same risk, they can be merged into one law enforcement agency."
In practice, this article can be used for institutional integration and functional configuration.
The other is to establish a coordination committee or other coordination agency to coordinate law enforcement while maintaining the independence of various law enforcement agencies, that is, the "coordination" method.
Since the supervision of medical security funds involves multiple administrative law enforcement agencies such as medical security, health, traditional Chinese medicine, market supervision and management, civil affairs, finance, auditing, and public security, the functions of these agencies are not just to deal with the same kind of risk. Merged into one law enforcement agency.
Therefore, the use of medical security funds should be supervised by a coordination method, that is, each law enforcement agency discusses, coordinates law enforcement arrangements and shares law enforcement information with other law enforcement agencies through coordination agencies and related coordination mechanisms, without the need for agency mergers and reorganizations.
Using a coordination method, a "lead coordination agency" is usually arranged in each corresponding regulatory field.
The agency can notify other agencies of the results of on-site inspections, and can also obtain corresponding information from other agencies.
Through this method of "mutually acting as eyes and ears", it can increase the probability of illegal acts being discovered and improve the effectiveness of law enforcement inspections.
In addition, when inspecting micro-, small- and medium-sized enterprises or institutions whose technologies are not too complicated and whose violations have caused limited social losses, front-line inspectors can receive special training and undertake a wider range of enforcement inspection tasks in a number of different regulatory fields; once If they find related problems, they can request more professional inspectors working in different regulatory and law enforcement agencies to conduct inspections.
These front-line inspectors are actually the "eyes and ears" of multiple institutions, and their inspections can replace some more professional inspectors at a lower cost to a certain extent.
In order to make better use of the above coordination methods, various regulatory agencies should establish a unified law enforcement information system, or connect the existing law enforcement information systems in other ways; any law enforcement inspection agency can systematically and other law enforcement agencies Share all relevant data, and where possible, share inspection and enforcement plans and plans.
There is evidence that the illegal behavior of a regulated enterprise or institution in one regulatory field often indicates that it may also violate the law in another regulatory field. Therefore, sharing information is extremely important.
When supervising the use of medical security funds, medical security administrative departments should strengthen information exchange and sharing with relevant departments, innovate supervision and management methods, promote the use of information technology, and establish a unified, efficient, compatible, convenient and safe nationwide medical treatment. Guarantee the information system, implement real-time dynamic intelligent monitoring of big data, and strengthen the management of the whole process of using shared law enforcement data to ensure the security of shared data.
In addition, various law enforcement agencies should also coordinate in specific law enforcement inspections and punishments.
Departments such as medical security, health, traditional Chinese medicine, market supervision and management, finance, auditing, and public security shall coordinate and cooperate with each other, and establish mechanisms for communication and coordination and case transfer.
(Author: Zhang Qing, the Department of China University of Political Science Professor)
Further reading
Current violations of regulations and laws in the pharmaceutical field
According to statistical data, in 2019, medical insurance bureaus at all levels conducted "double random" inspections on the two designated medical institutions, investigating and punishing 11.5 billion yuan in violations of laws and regulations.
The investigation found that the following problems mainly exist:
The first is serious fraud and insurance fraud.
It is manifested as false listing of medical items, violations of regulations, cross-swap, over-standard charges, grouping, decomposition, repeated charges, lowering of standards, false hospitalization and other illegal activities.
For example, a private hospital falsified medical expenses involving 480,351.40 yuan, of which the falsified ultrasound examination "color one-time imaging (Pola) photo" cost involved 7,858 yuan, etc.; the people’s hospital falsified medical expenses involving 752276.67 yuan, of which "venous indwelling needle" "The limit price of super medical insurance involves 17,751 person-times, and the cost is 635803.67 yuan; there is also a charge of 127,5316.72 yuan for the change of diagnosis and treatment items, of which the ordinary "blood pressure test" is changed to "ambulatory blood pressure monitoring", which involves 13,417 person-times, and the amount is 651876.00 yuan. Including "Urine Sediment Microscopic Examination, Urine Sediment Quantitative Flow Cytometry" and "Set" test, involving 19,551 person-times worth 288,953.00 yuan and so on.
Second, the violation of health policies by the management of medical institutions is widespread.
Many hospitals have failed to comply with health policies and regulations in setting up beds, equipment, and departments. On-duty physicians have no relevant qualifications, and the management of purchase, sale and inventory is chaotic.
For example, the district hospital of traditional Chinese medicine carried out rehabilitation diagnosis and treatment projects without rehabilitation technicians, which involved 26787 person-times of 37,6340.00 yuan.
Conducting CT operations without "CT" technicians involved 15,582 person-times of 1,391,150.00 yuan; District People’s Hospital's MRI scanning large-scale medical equipment operators were unqualified, and nuclear magnetic inspections involved 5254 person-times of 2,29,3992.0 yuan.
The hospital’s medical-care ratio is not up to standard, with a shortage of 46 doctors and a shortage of 134 nurses; a private hospital has 557 beds and 20 hemodialysis machines, and the "Medical Institution Practicing License" approved the hospital with 300 beds and hemodialysis machines17 Taiwan; the inventory management of medicines, consumables, etc. generally fails to comply with relevant regulations. The documents accompanying the goods are not stamped with the “special seal for delivery”, and there is a phenomenon of white bars on top of the warehouse. Some medicines in outpatient pharmacies have supplier debts, damaged medicines, and purchase There is no inspector for the acceptance records in the warehouse, and no inventory of high-value consumables, interventional consumables, and chemical reagents.
The third is the serious loss of funds from medical institutions.
On the whole, the inspected hospitals generally have financial irregularities, cash payments, blank entry accounts, and long-term accounts of large funds. Some private hospitals have the same day income directly transferred to the investor’s account and purchased with the hospital’s operating income. Real estate developed by investors and so on.
For example, a group of five accounting vouchers in a private hospital have no signature "withdraw" or "white strip", totaling 17.16 million yuan.
The hospital has a long-term account payable (a pharmaceutical company) of more than 50 million yuan.
The hospital also opened a "gold card" business, promising that gold card members enjoy free self-pay items, and the gold card income of 5 million yuan is directly deposited into the personal accounts of the hospital leaders’ family members; the district people’s hospital accepts a value-added tax invoice of more than 3 million yuan from a pharmaceutical company. The results of the query on the VAT invoice query platform of the State Administration of Taxation were "inconsistent" ("suspected" fake invoices).
In addition, many private hospitals have also set up a "discount card" business. In one private hospital, the hospitalization rate and number of people during the hospitalization period were 269 people with 50% reduction, 106 people with 100% reduction, and 409 people with 10% reduction, totaling 784 people.
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my country has its first medical insurance regulatory draft
The "Regulations on the Supervision and Administration of the Use of Medical Insurance Funds (Draft)" passed on the 9th by the executive meeting of the State Council will change the lack of special laws and regulations in the supervision of medical insurance funds in my country, strongly promote the administration of medical insurance in accordance with the law, and improve the level of medical insurance governance.
It is reported that the medical insurance regulatory bill insists on focusing on people’s health, defines the rights and responsibilities of medical insurance departments, designated medical institutions, and insured personnel, stipulates that in accordance with the principle of convenience, strengthen medical security services, promptly settle and allocate medical insurance funds, and improve service quality , Requires strengthening supervision and social supervision, strictly prohibits fraudulent acquisition of medical insurance funds through forgery or alteration of medical documents or fictitious medical services, and intensifies punishments for violations of laws and regulations by ordering the return of funds, suspending medical insurance settlement, fines, and revoking the qualifications of designated medical institutions. Manage and use medical insurance funds well to safeguard the legitimate rights and interests of the masses in medical insurance.
Since its establishment, the National Medical Insurance Bureau has always regarded strengthening fund supervision and maintaining fund safety as an important political task, continued to increase supervision and inspection, maintained a high-pressure situation of combating fraudulent insurance, and seriously investigated and dealt with fraudulent insurance fraud.
At present, 10 provinces including Beijing and Tianjin have established full-time medical insurance fund supervision institutions at the provincial level, and dozens of cities and counties (districts, cities) including Alxa League in Inner Mongolia, Xuzhou City in Jiangsu Province, and Jining City in Shandong Province Special administrative law enforcement teams for fund supervision have been established one after another, and the strength of fund supervision personnel has been effectively strengthened.
(According to Xinhua News Agency)