The draft of the Medical Security Law is announced and plans to severely punish all types of insurance fraud
Prevent medical insurance "life-saving money" from turning into "tang monk meat"
□ Our reporter Zhao Chenxi
On June 15, the National Medical Security Administration announced the "Medical Security Law (Draft for Comment)" (hereinafter referred to as the Draft for Comment).
The draft has 8 chapters and 70 articles, which stipulate the financing and benefits of medical insurance, fund management, medical services, public management services, supervision and management, and legal responsibilities.
As the basic law of my country's medical security, the release of the draft for solicitation of opinions can be described as "beginning with endless calls."
The promulgation of this law will solve the overall unreliable problem of medical security reform and development, and will have a positive and far-reaching impact.
"The issuance of the draft for consultation indicates that my country's medical security has officially entered the track of the rule of law." Li Changan, a professor at the National Opening-up Research Institute of the University of International Business and Economics, pointed out in an interview with a reporter from the "Rules of Law Daily" that after the official introduction of the medical security law , Will effectively promote the administration of medical insurance in accordance with the law to improve the governance of medical insurance.
Medical insurance lacks uniform legislation and regulations
Medical security is one of the most important social security systems. It is related to the vital interests of all people. However, my country's medical security system has always lacked proper legal norms.
Li Changan said that the current law based on medical security in my country is mainly the "Social Insurance Law of the People's Republic of China" that was implemented in 2011, but the main content of this law is the regulation of basic medical insurance for employees and cannot cover the entire medical security system.
In March 2020, the "Opinions on Deepening the Reform of the Medical Security System" issued by the Central Committee of the Communist Party of China and the State Council clearly stated that it is necessary to promote the development of a multi-level medical security system, encourage social charitable donations, coordinate the mobilization of charity medical assistance, and support orderly mutual medical assistance. development of.
At the same time, it is proposed that by 2030, a comprehensive medical security system with basic medical insurance as the main body, medical assistance as the foundation, supplementary medical insurance, commercial health insurance, charitable donations, and mutual medical assistance will be established.
"This top-level design for deepening the reform of the medical insurance system in the new era has made it clear that the medical insurance system to be developed in my country is a multi-level and complete system." Li Changan pointed out that although various localities have introduced supplementary medical insurance, medical assistance, and commercial health insurance, etc. Some policies, but due to the lack of unified legislative norms, the medical security policies introduced by various regions are quite different, and a complete medical security law is urgently needed to regulate them.
In 2018, the National Medical Security Administration was established to formulate policies and standards for medical insurance, maternity insurance, and medical assistance, and organize their implementation.
A reporter from the "Rule of Law Daily" entered the website of the National Medical Insurance Administration and typed "Medical Security Law" in the search bar. The latest news was the National Medical Insurance Administration's reply to the National People's Congress's recommendations on medical security legislation.
At the National People's Congress in the past two years, many representatives put forward proposals and suggestions on medical security legislation.
During the third session of the 13th National People's Congress in 2020, Zheng Gongcheng, a member of the Standing Committee of the National People's Congress and president of the Chinese Society of Social Security, led the proposal on enacting a medical security law as soon as possible.
Also in 2020, Hu Jiqiang, deputy to the National People's Congress and chairman of Conba Group Co., Ltd., also proposed to formulate a medical security law.
Hu Jiqiang said that the reform of the medical security system involves the adjustment of interests in all aspects. If the medical security undertaking is not legislated at the national level, the reform of the medical security system and the development of my country’s medical insurance undertaking will be unfounded.
At this year’s National People’s Congress, NPC deputy and director of the Jiangxi Provincial Medical Security Bureau Mei also suggested speeding up the legislative process of the Medical Security Law.
She pointed out that my country must have a programmatic and comprehensive medical security law to guide and escort the implementation of the high-quality development of medical security.
This consultation draft stipulates that the state establishes a medical security system with basic medical insurance as the main body, medical assistance as the foundation, supplementary medical insurance, commercial health insurance, and charity medical assistance, which are mutually connected and developed together.
"This will make our country's multi-level medical security system have laws to follow, provide a top-level design for comprehensively promoting the reform of the medical security field, and take an important step in the construction of my country's legal system in the field of medical security." Li Changan believes that the draft for comments The announcement itself is the biggest bright spot.
Medical reform expert Wei Zining pointed out that medical security involves multiple levels of interest among governments at all levels, insured persons, employers, medical insurance management agencies, and medical institutions. The formulation of the Medical Security Law will make the division of rights and responsibilities of all parties involved more clearly. .
Standardize the management of commercial health insurance
As an important part of the multi-level medical security system, commercial health insurance has received more and more attention in recent years.
Data show that China's commercial health insurance premiums have increased from 158.7 billion yuan in 2014 to 817.3 billion yuan in 2020, an average annual increase of 31.4%.
AIA senior salesman Lu Xin introduced that commercial health insurance is based on the insured’s body as the object of insurance to ensure that the insured’s direct costs or indirect losses in the event of injury caused by illness or accidents are compensated for, including sickness. There are five categories: insurance, medical insurance, medical accident insurance, nursing care insurance, and disability income loss insurance.
From pursuing sales in the past, to now people are actively consulting, in Lu Xin's view, people's awareness and acceptance of commercial health insurance continue to increase, thanks to the country's many policies to support the development of commercial health insurance in recent years.
In August 2014, the State Council issued "Several Opinions on Accelerating the Development of Modern Insurance Service Industry" to encourage insurance companies to vigorously develop commercial health insurance products and provide health management services integrated with health insurance; the "General Office of the State Council" issued in November 2014 The "Several Opinions on Accelerating the Development of Commercial Health Insurance" is the first special document to comprehensively deploy the development of commercial health insurance at the national level; in December 2016, the "Thirteenth Five-Year Plan for Deepening the Reform of the Medical and Health System" promulgated by the State Council Commercial health insurance development" is included as an important measure...
The draft for comments also proposes to encourage the development of commercial health insurance.
Article 21 stipulates that the development of commercial health insurance is encouraged, and commercial insurance companies are supported to expand the scope of insurance products such as critical illness insurance.
Encourage employers and urban and rural collective economic organizations to purchase commercial health insurance for their employees and members in accordance with regulations.
Lu Xin revealed that although there are currently more than 5,000 commercial health insurance products sold, with the enrichment of consumer groups on the demand side, higher requirements have been placed on health insurance products. The legislation clearly supports insurance companies to expand the product range. Help further enrich commercial health insurance products.
Li Chang'an paid attention to the stipulation that "the medical security administrative department of the State Council, in conjunction with relevant departments, regulate the management of commercial health insurance and promote the orderly development of commercial health insurance."
This means that in the future, the national medical insurance department will also have certain regulatory authority over commercial health insurance. The current commercial health insurance is mainly supervised by the China Banking and Insurance Regulatory Commission. In the future, the supervision of the two departments will be combined.
"Although my country's commercial health insurance is developing steadily, there are still many irregularities and even frauds in the course of business development of insurance companies. Strengthening supervision is of great significance." Li Changan pointed out that from a functional point of view, the China Banking and Insurance Regulatory Commission is responsible for financial supervision. , The relevant content of the medical security field is definitely not as good as the medical insurance department. After the medical insurance department joins the supervision, it can improve the health insurance supervision system on the one hand, and also help promote the professional development of commercial health insurance.
The dual supervision of the two departments, each performing its own duties, will further achieve precise supervision.
Increase efforts to punish insurance fraud
When it comes to the supervision of the medical security field, one has to mention the medical security fund, which is the most difficult to supervise. Due to the large number of users and the long chain, the problem of insurance fraud has been repeatedly banned, and "life-saving money" has become "tang monk meat."
In 2020, the National Medical Insurance Bureau will inspect more than 600,000 designated medical institutions in conjunction with health departments, deal with more than 400,000 institutions that violate laws and regulations, and recover 22.31 billion yuan in medical insurance funds. More than half of the designated medical institutions have problems with the use of funds.
With the same medical insurance account, more than 10 kinds of medical insurance drugs can be allocated in 5 medical institutions in this city within one day; the same person, carrying 3 other medical insurance cards at the same time, can dispense more than 30 boxes of medical insurance drugs in many medical institutions in this city... Recently, the Economic Investigation Corps of the Shanghai Public Security Bureau took the lead in launching special operations in the city, successfully detecting multiple cases of medical insurance fraud.
After investigation, there are two common forms of insurance fraud: one is the middle-aged and elderly people who go to see a doctor randomly by the suspect at the entrance of the hospital, and offer to pay several hundred yuan a month in remuneration, and rent someone else’s medical insurance card. Then, under the pretext of prescribing medicines by relatives and friends, they use other people’s medical insurance cards to dispense medicines, and then illegally profit from reselling; the other is that the criminal suspect goes directly to the medical institution and colludes with internal staff, without any medical treatment or dispensing behavior. Under the circumstances, false diagnosis and treatment prescriptions and medicines were issued to defraud medical insurance funds.
The Draft for Opinions stipulates that if individuals give their medical insurance certificates to others for false use, repeated enjoyment of medical insurance benefits, etc., causing losses to the medical insurance fund, they shall be ordered to return them; if they belong to insured persons, their online medical expenses settlement shall be suspended for 3 months to 12 months.
Individuals who defraud the expenditure of the medical security fund will also be fined by the medical security administrative department of more than 2 times and less than 5 times the amount defrauded.
In addition, if designated medical institutions and their staff defraud medical security fund expenditures, in addition to fines of 2 times to 5 times the amount defrauded, their practice qualifications will also be revoked; designated medical institutions violate the regulations and cause major losses to the medical security fund In addition to fines, they will also be prohibited from engaging in management activities of designated medical institutions within 5 years.
In response to the fraudulent insurance behaviors of different entities, in addition to fines, the draft for comments also adds targeted additional penalties.
In the view of He Jingjun, associate professor of the School of Politics and Public Administration at Southwest University of Political Science and Law, this helps to increase the deterrence of the law and combat insurance fraud.
However, he noticed that the draft for comments on the legal responsibility of local governments for inaction or misconduct in medical security work is less involved, and he suggested that more regulations should be made on the supervision of local government behaviors.