What are the means of fraudulent insurance? Why not stop after repeated bans? How to protect individuals? ——The “three two things” of dialysis medical insurance fund supervision
Xinhua News Agency, Beijing, February 25th: What are the methods of fraudulent insurance?
Why not stop after repeated bans?
How to protect individuals?
——The “three two things” of dialysis medical insurance fund supervision
Xinhua News Agency reporters Peng Yunjia, Gong Wen, Shuai Cai
The medical insurance fund is a "pocket" for the people to see a doctor, but some people regard the medical insurance fund as a "tang monk meat" and try to "drip and leak" from it to defraud the medical insurance fund.
What are the means of fraudulent insurance?
How to protect the "life-saving money"?
The State Council recently promulgated the "Regulations on the Supervision and Administration of the Use of Medical Insurance Funds" to provide a "big punch" to the use and supervision of medical insurance funds.
In the face of fraud and insurance, ordinary people have to keep their eyes open.
Be vigilant! Various methods of fraudulent insurance
The National Medical Insurance Bureau recently exposed the first batch of fraudulent insurance cases in 2021, including: Huang Moumou, president of Jinjing Hospital in Jinzhou City, Liaoning Province, and many people inside and outside the hospital handled false hospitalizations by borrowing medical insurance cards for employees, residents, and students, and fraudulently obtained medical insurance The fund was more than 2.9 million yuan; Li XX, the vice president of Wangchengpo Chunwang Hospital in Changsha City, Hunan Province, and Liu XX, the dean and legal person, defrauded the medical insurance fund of more than 4.25 million yuan in laboratory inspections...
In recent years, medical insurance fraud methods have been continuously upgraded, which can be described as "various":
—— Excessive medical treatment and treatment of minor illnesses increase expenditure.
Some hospitals push up medical expenses through unreasonable inspections, treatments, and medications, which not only increase the burden on patients but also increase medical insurance expenditures.
——Hanging bed for hospitalization, fraudulent treatment to obtain medical insurance fund.
Some medical institutions admit patients who do not meet the admission requirements, hang out to reimburse outpatient expenses, and even make up fictitious treatments.
——Swap medicines, split the charges, and set up names to deceive insurance in disguise.
Individual medical institutions have resorted to swapping drugs with higher charges, or retail pharmacies selling daily necessities by swapping drugs, or even directly using cash-out methods to cheat insurance.
——Excessive medication, waste of money and damage to health.
In order to defraud medical insurance funds, some hospitals use non-essential medications for patients and switch frequently during the trial period.
-Inducing medical treatment, doctors and patients colluded to defraud insurance.
Some private medical institutions use medical examinations, rebates, cash rebates, etc. to induce insured persons to be hospitalized, colluding with patients to defraud insurance.
Why cheat protection "emerges in endlessly"
"In recent years, medical insurance fraud has been high and frequent." Qin Yunbiao, political commissar of the Criminal Investigation Bureau of the Ministry of Public Security, said at a press conference a few days ago that in 2020 alone, public security agencies across the country have investigated 1,396 such cases and arrested 1,082 criminal suspects. More than 400 million yuan of medical insurance funds were recovered.
Why does fraud and protection "emerge in endlessly"?
In the final analysis, it is still driven by interests and "free to drill."
"Some insured persons always think that if they pay medical insurance premiums, they will suffer a loss if they don't." Yang Yansui, a professor at the Institute of Hospital Management of Tsinghua University, said that if the insured has such awareness, it is easy to be "set down" by a small number of medical institutions and practitioners. Form a community of interests and cannibalize the medical insurance fund.
At present, the supervision of medical insurance funds mainly focuses on "after-the-fact supervision", and lacks a closed-loop supervision chain for the reimbursement subject before and during the event.
Li Wenxing, secretary of the Disciplinary Committee of Zigong City, Sichuan Province, said that the supervision of medical insurance funds is a highly professional supervision, and some unreasonable or even illegal acts are difficult to identify and require professionals.
"At present, an average of 1 staff member in Zigong City has to serve 17,645 insured persons." Li Wenxing said, Zigong City has 158 employees in all levels of medical insurance administrative agencies and agencies, corresponding to more than 1,300 designated medical institutions, with 2,787,900 insured persons. People are prone to blind spots in supervision.
Li Yuanxin, director of the Institute of Health Policy and Medical Management of Shanghai Jiaotong University, said that the corresponding supervision system and mechanism need to be continuously improved, and the responsibilities of medical insurance agencies, designated medical institutions and other entities should be continuously enhanced.
"Targeted therapy" for cheating insurance with heavy punches
——Strengthen the legal system construction of medical insurance fund supervision
"The issuance of the regulations will greatly enhance the supervision of medical insurance funds." The relevant person in charge of the National Medical Insurance Bureau said that the "Regulations on the Supervision and Administration of the Use of Medical Security Funds" implemented on May 1, 2021 will provide a solid legal system for the safe and effective use of funds. basis.
——In-depth implementation of special governance to combat fraud and insurance
The National Medical Insurance Administration has carried out special treatments against fraudulent insurance for three consecutive years.
In 2020 alone, a total of 401,000 medical institutions in violation of laws and regulations were handled nationwide, and 22.31 billion yuan of medical insurance funds were recovered.
The key to effectively implementing the supervision of medical insurance funds lies in showing an attitude of "relentlessness."
In response to the embezzlement, arbitrage, and fraudulent acquisition of medical insurance funds, the Commission for Discipline Inspection of Zigong City, Sichuan Province has established a work mechanism for combating fraudulent insurance, and carried out 4 projects such as combined ultrasound therapy and hemodialysis to establish a network of inspections. A solid firewall.
As of September 2020, Zigong City has recovered 43,886,100 yuan of medical insurance funds.
The key to effectively combating fraudulent insurance is also the "second half of the article" for supervision and management.
The Zigong Medical Insurance Bureau has improved the "blacklist" and personal punishment systems, and promoted reforms, treatment and construction by cases.
——Establish and improve the reward mechanism for reporting
According to the relevant person in charge of the National Medical Insurance Bureau, in 2020, a total of 1,133 whistleblowers will be rewarded nationwide, an increase of 88.5% year-on-year, and a bonus of 2,141,600 yuan will be issued, a year-on-year increase of 1.47 times.
The role of mass supervision has become increasingly obvious.
To improve self-protection awareness, the public must also "say no" to fraudulent insurance.
In the face of fraudulent insurance, the public can call the National Medical Insurance Bureau's reporting telephone number: 010-89061396 (7), or dial local reporting telephones, or report on the WeChat official account of the National Medical Insurance Administration, or submit written materials.