On April 20, the official website of the National Medical Insurance Bureau announced the "Circular on The Special Flight Inspection of tongji Hospital Affiliated to Tongji Medical College of Huazhong University of Science and Technology".
In March 2022, based on the tip-off, the National Medical Insurance Bureau, together with the National Health Commission and the State Administration of Market Regulation, conducted a flight inspection of the Tongji Hospital affiliated to Tongji Medical College of Huazhong University of Science and Technology (hereinafter referred to as "Wuhan Tongji Hospital"), and guided the Hubei Provincial Medical Insurance Bureau and the Wuhan Municipal Medical Insurance Bureau to verify and deal with the relevant issues.
After investigation, it was found that from January 2017 to September 2020, Tongji Hospital had the problem of collusion and false recording of high-value medical consumables in orthopedics, and defrauded the medical insurance fund to pay 23343609.64 yuan.
The Wuhan Municipal Medical Insurance Bureau made the following treatment:
1. Order rectification;
2. The hospital will be fined 38.31 million yuan twice the amount of 19.16 million yuan for defrauding the medical insurance fund, and 5 times the amount of 4.18 million yuan found by the inspection is 5 times fine of 20.93 million yuan, a total of 59.25 million yuan;
3. Order the hospital to suspend the medical services used by the medical security fund for 8 months in the orthopedic department;
4. Transfer clues to the relevant departments such as public security, market supervision, drug supervision, health and health, and discipline inspection and supervision in accordance with laws and regulations. At present, the losses of the medical insurance fund have been fully refunded, and the fines have been fully enforced.
Tongji Hospital's problems are not limited to orthopedics. The flight inspection also found that other medical acts in Tongji Hospital in 2021 were suspected of using the medical insurance fund of 91.0741 million yuan in violation of the law, and are still being further verified and processed.
On April 19, Tongji Hospital issued the "Tongji Hospital's Handling of the Loss of medical insurance funds caused by the illegal settlement of false consumables and product regulation information by orthopedic departments", saying that the penalty decision was "fully accepted and resolutely rectified".
The punishment for being found out and self-examination and voluntary return is very different: the former is punished with a 5 times fine; the latter is a confessional leniency, and the penalty is 2 times.
The fine was nearly 60 million, which is a rare case of a large-scale third-class public hospital being punished. In 2021, in the "China Hospital Comprehensive Ranking" released by the Institute of Hospital Management of Fudan University, Wuhan Tongji Hospital ranked sixth in the country and first in Central South China. It is understood that Tongji Hospital has ranked in the top ten of the national ranking for 10 consecutive years, ranking first in central China and is the benchmark of central medical care.
According to the Social Insurance Law and the Regulations on the Supervision and Administration of the Use of Medical Security Funds, in addition to returning the medical insurance fund involved in the case, a fine of 2-5 times must be paid. That is to say, after paying the 59.25 million yuan of fines for orthopedic violations, Tongji Hospital may also have to pay a fine of at least 182 million yuan and a maximum of 455 million yuan, and the total amount of fines may exceed 500 million.
According to the budget plan of Tongji Hospital, the budget revenue of Tongji Hospital in 2021 is 11.929 billion yuan.
According to the 2022 National Anti-Fraud and Insurance Fraud Special Rectification Action Teleconference held on March 31, a total of 708,000 designated medical institutions were inspected in 2021, 411,000 were investigated and punished, and 23.4 billion yuan of medical insurance funds were recovered.
This also means that more than half of the medical institutions tested cannot withstand the investigation. So why are there always hospitals using Medicare funds in violation of the law? The health community interviewed Wang Zhen, director of the Public Economics Research Office of the Chinese Academy of Social Sciences, to explain the medical insurance fund supervision system behind the high fines.
"Price 5 yuan, report 10 yuan"
The Wuhan Municipal Medical Security Bureau issued a notice saying that according to the tip-off clues, the bureau investigated the use and settlement of the medical insurance fund for high-value consumables in the department of orthopedics of Wuhan Tongji Hospital, and found that the orthopedic department of the hospital had the problem of illegal settlement with false consumables product regulation information, resulting in a loss of 23.34 million yuan in the medical insurance fund.
What is "False Consumables Specification Information Violation Settlement"?
"Orthopedics uses more high-value consumables, accounting for the majority of medical expenses, and there are large price differences between different products." Wang Zhen, director of the Public Economics Research Office of the Chinese Academy of Social Sciences, gave an example: A product with a price of 5 yuan is reported as 10 yuan, which is a common violation.
According to upstream news reports, about two months ago, after receiving reports from industry insiders, a high-level investigation team composed of many people from multiple departments came to Wuhan Tongji Hospital to carry out a comprehensive investigation, focusing on the settlement price of orthopedic consumables implanted in the body.
After investigation, "the hospital is shoddy, for example, the steel plate implanted in the body is 200 yuan, but the hospital writes 600 yuan." In this way, patients bear more and lose more health insurance benefits."
According to upstream news reports, the head of the orthopedic department of Tongji Hospital has been taken away by the judicial authorities.
According to the official website of Wuhan Tongji Hospital, the Department of Orthopedics of the hospital was founded in 1946 and is a national key clinical specialty and a quality control center of orthopedic medical care in Hubei Province.
The current director and academic leader of the Department of Orthopedics of Tongji Hospital is Li Feng. On April 20, the official website and public account of Tongji Hospital showed that Li Feng's expert number could still be registered normally.
It is worth noting that the notice is aimed at the investigation between January 2017 and September 2020. Wang Zhen mentioned that these may be the results of the investigation of the historical behavior of the hospital, and with the increase in the supervision of the medical insurance fund in the past two years, the future medical insurance violations will be less and less.
Hospitals forced to be helpless?
This is not the first time that medicare has fallen on the orthopedic departments of public hospitals.
In April 2021, the Zhengzhou Municipal Medical Insurance Bureau of Henan Province, based on the investigation of real-name reporting clues, found that the Sixth People's Hospital of Zhengzhou City had the problem that the surgical records of the use of pedicle screws did not match the actual implantation, resulting in a loss of 1.74 million yuan in the medical insurance fund.
The results of the local health insurance department are as follows:
1. Cancel the medical insurance service payment qualifications of the responsible persons such as Chen XX, director of the Orthopedic Department of the hospital, and Qian XX, director of the Orthopedic Tuberculosis Department;
2. From 00:00 on April 28, 2021, suspend the settlement of the medical insurance fund for the Orthopedic Department and the Department of Orthopedic Tuberculosis of the hospital;
3. Recover the lost medical insurance fund and impose a fine of 5 times;
4. The clues of relevant problems are transferred to the Discipline Inspection and Supervision Team of the Zhengzhou Municipal Commission for Discipline Inspection and Supervision, the Municipal Public Security Bureau and the Municipal Market Supervision Bureau. At present, the discipline inspection and supervision team appointed by the Zhengzhou Municipal Commission for Discipline Inspection and Supervision has filed a case for review (investigation) by Chen X, director of the orthopedic department of the hospital, and Lei X, chief of the medical equipment section; the Second Seventh Branch of the Zhengzhou Municipal Public Security Bureau has filed a case to investigate the clue; the 1.74 million yuan of the lost medical insurance fund has been fully returned, and the 5 times fine of 8.71 million yuan has been fully implemented.
On April 19, on the occasion of the hot search for insurance fraud in Tongji Hospital, the People's Government of Henan Province issued an article entitled "Jiaozuo City Launches a Special Rectification Action to Combat Fraud and Insurance Fraud", saying that Jiaozuo City will severely crack down on fraudulent insurance fraud and insurance violations such as fake patients, fake diseases, and fake bills, focusing on areas with high incidence of fraud and insurance fraud such as collusion of drugs and high-value medical consumables, especially for high-value medical consumables fraud and insurance fraud in orthopedics.
The fraud method of the Sixth Hospital of Zhengzhou in 2021 has similarities with Tongji Hospital: shoddy charging. In surgery, lower-priced medical consumables are used to replace similarly priced medical consumables and implanted into the patient's body.
After the exposure of the insurance fraud incident of the Sixth Hospital in Zhengzhou, Guan Handanfeng, deputy chief physician of the Department of Orthopedics of Wuhan Tongji Hospital, was interviewed by Ding Xiangyuan and said: Although major hospitals have instrument management processes, there may be some irregular problems in the operating room, resulting in space for sleeve labels. A year later, the East Window of the Department of Orthopedics of Wuhan Tongji Hospital, where Guan Handfeng was located, occurred.
In 2021, the "China Hospital Comprehensive Ranking" and "China Hospital Specialty Reputation Ranking" released by the Institute of Hospital Management of Fudan University and the Health Community, the comprehensive ranking of Tongji Hospital affiliated to Wuhan Tongji Medical College ranked sixth in the country and first in Central And South China. It is understood that Tongji Hospital has ranked in the top ten of the national ranking for 10 consecutive years, ranking first in central China, is the benchmark of central medical treatment, and will be promoted to another place in 2021, ranking first in central and southern China.
The punishment of the top ten public tertiary hospitals in the country shows the regulatory determination of the medical insurance department.
Expand the scope to more hospitals: On February 8, 2022, the Sichuan Provincial Medical Security Bureau exposed the first typical case of medical insurance violations in 2022, of which Suining Central Hospital illegally settled the medical insurance fund of up to 9.812 million yuan, which was recovered from the default medical insurance fund, and the hospital was also punished with double the liquidated damages.
In June 2019, the National Medical Insurance Bureau found during the flight inspection that the Second Xiangya Hospital of Central South University had serious violations of the use of medical insurance funds such as falsely remembering the cost of consumables such as surgical sutures and excessive medical treatment, and the result of the treatment at that time was to recover all the illegal medical insurance funds and impose a total fine of 33.5926 million yuan, and dealt with 4 hospital-level leaders and 15 middle-level cadres of the illegal departments accordingly.
On May 10, 2021, the National Medical Security Bureau again reported two cases of illegal settlement of medical insurance funds reaching the level of 10 million, namely Hainan Provincial Hospital of Traditional Chinese Medicine and Zunyi First People's Hospital, involving medical insurance funds of 15.69 million yuan and 15.58 million yuan respectively.
In May 2021, after an investigation by the Qinzhou Municipal Medical Insurance Bureau of Guangxi Province, it was found that qinzhou Traditional Chinese Medicine Hospital had problems such as charging for cross-cutting items, excessive examination, and excessive treatment between January 2020 and April 2021, involving a medical insurance fund of 2 million yuan.
The results of the local medical insurance department's treatment included the suspension of the medical insurance service payment qualifications of 11 people, including Zhang X and Zhao X of the first district of the acupuncture department of the hospital, and Zhong xx and Han X of the second district of the Tuina Department, for 3 months; and suspended the medical insurance fund settlement of the first district of the acupuncture department and the second district of the Tuina department of the hospital for 3 months.
On April 23, 2021, the exposure desk of the Hainan Provincial Medical Security Bureau released the typical cases of the second phase of exposure in 2021, showing that the Hainan Provincial People's Hospital had serious violations such as overcounting the cost of medical consumables, excessive inspection and repeated collection of medical service project fees, and the medical insurance funds used in violation of the law were as high as 54 million yuan.
According to Jiang Chengjia, director of the Department of Fund Supervision of the National Medical Insurance Bureau, at the media briefing, from 2018 to October 2021, the national medical insurance department inspected about 2.34 million designated medical institutions, handled about 1 million times, and recovered about 50.6 billion yuan of medical insurance funds.
In terms of time and quantity, the illegal use of medical insurance funds seems to have been repeatedly prohibited.
Wang Zhen analyzed that on the one hand, it is related to "human consciousness": medical staff can borrow medical insurance for benefits; on the other hand, it is related to historical reasons: hospitals can rely on these irregularities to maintain hospital operations.
In the eyes of some hospitals and doctors, the illegal use of medical insurance funds is a choice they are forced to make.
Under the new medical reform, the implementation of measures such as medical insurance control fees, drugs and consumables bonus cancellation has once reversed the previous situation of "it is easy for hospitals to make money", coupled with the epidemic that lasted for three years, most hospitals have experienced a sharp decline in business volume, doctors' income has declined, and hospitals are facing greater operational pressure.
However, this is not the reason for the hospital to use the medical insurance fund in violation of the law and fraudulently cheat the insurance, and Wang Zhen even believes that this is "unreasonable trouble", "If you follow this logic, the enterprise can also go to robbery if it goes out of business."
Wang Zhen said that the correct choice for hospitals in this case is high-quality development, relying on quality and efficiency to get out of the predicament, "operational pressure will force hospitals to abandon the previous model of fighting for scale and number of beds, so as to embark on the road of high-quality development."
Medicare regulation, from scratch
An important reason for the illegal use of medical insurance funds by hospitals is that the original regulatory system system is not perfect. Before the establishment of the National Medical Insurance Bureau, the severe punishment measures for insurance fraud were relatively lacking, and the relevant laws and regulations were not perfect.
Since the establishment of the National Medical Insurance Bureau in 2018, together with the National Health Commission, the Ministry of Public Security, and the State Food and Drug Administration, it has jointly carried out special actions to combat fraud and deception of medical security funds, and set up exposure stations on the official website to encourage the people to report fraud and deception of medical security funds.
In February 2021, the Regulations on the Supervision and Administration of the Use of Medical Security Funds came into effect, completely ending the lack of special laws and regulations in the field of medical security in the mainland.
At the end of 2021, the National Medical Insurance Bureau and the Ministry of Public Security issued the Notice on Strengthening the Investigation and Handling of Cases of Fraudulent Medical Insurance Funds, requiring that the execution linkage work of investigating and handling cases of fraudulent medical insurance funds be effectively strengthened, and the scope of transfer of cases of fraudulent medical insurance funds be clarified.
In January 2022, the National Medical Insurance Bureau issued the Interim Measures for the Handling of Reports on the Supervision and Administration of the Use of Medical Security Funds, encouraging social supervision and public opinion supervision of insurance fraud.
The Interim Measures, which came into effect on 1 March 2022, provide:
Article 23: All levels of administrative departments for medical security shall appoint professional personnel to provide necessary office space, office equipment, and so forth, to ensure the smooth progress of efforts to receive and handle reports;
Article 24: Reports of illegal use of medical security funds such as resident major illness insurance, large medical expense subsidies for employees, and medical subsidies for civil servants shall be handled with reference to these Measures.
"Since the establishment of the National Medical Insurance Bureau, the supervision of medical insurance funds has gradually built a long-term mechanism for the supervision of medical insurance funds from scratch, from weak to strong, from rough to fine." Wang Zhen said.
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Written by | Yang Ruijing