Behind the huge insurance fraud case of Tongji Hospital: the dilemma of medical insurance supervision of "big three"

Fraudulent insurance, Tongji Hospital, the amount involved in the case is nearly 100 million...

This is the first time that the National Medical Insurance Bureau has separately announced the results of a flight inspection of a hospital, and the industry is in an uproar - the top three, the top penalty, the amount is huge, and the nature is bad.

According to the National Medical Insurance Bureau, Tongji Hospital defrauded the medical insurance fund of more than 23.34 million yuan from 2017 to 2020, "colluding and falsely recording orthopedic high-value medical consumables".

In addition, more than 91.07 million yuan of medical insurance funds suspected of illegal use in 2021 are still being verified and processed.

The protagonist of the case, Tongji Hospital affiliated to Tongji Medical College of Huazhong University of Science and Technology, founded in 1900, is a top three hospital at the tip of China's pyramid, ranking sixth in the country in the 2020 "Comprehensive Ranking of Chinese Hospitals" released by the Institute of Hospital Management of Fudan University.

The announcement shows that the hospital self-inspected and voluntarily returned the amount of 19.15 million yuan, and after the inspection, it was found that the amount defrauded was 4.18 million yuan. The former imposed a 2 times fine – nearly 40 million, while the latter imposed a 5 times fine – more than 20 million.

In addition, the hospital was ordered to suspend the orthopedic department for 8 months of medical services involving the use of medical insurance funds.

This touches the maximum amount of the insurance fraud fine in the Regulations on the Supervision and Administration of the Use of Medical Security Funds promulgated in 2021: a fine of 2 times to 5 times the amount of fraud is imposed, and the designated medical institution is ordered to suspend the medical services used by the relevant responsible departments for 6 months to 1 year or less.

An informed source told Eight Points Jianwen that the inspection process was full of twists and turns, and there was a tug-of-war process on issues such as the intensity of investigation and punishment and how to expose it.

The first to expose the case was the Wuhan Medical Insurance Bureau. On April 18, the official website of the Wuhan Medical Insurance Bureau published the basic information of the department involved in the case, the time span, the amount of violation and the punishment measures. The subject of the inspection is the "Wuhan Municipal Medical Insurance Bureau", which is "illegal use of medical insurance funds".

On April 20, the National Medical Insurance Bureau once again released the relevant information about the case, the content was more detailed, directly characterized the case as "defrauding the medical insurance fund", and the inspection subject was "the National Medical Insurance Bureau, the United National Health Commission, the State Administration of Market Supervision", and "guided the Hubei Provincial Medical Insurance Bureau and the Wuhan Municipal Medical Insurance Bureau to verify and deal with relevant issues". And for the first time, it was revealed that there are still nearly 4 times the confirmed amount of illegal use of funds to be investigated.

A doctor who understands the Medical System in Wuhan told Eight Point Health News that the round of examinations has begun since the beginning of February, and the number of national flight inspection teams has reached dozens of people, and there are personnel drawn from other local medical insurance bureaus.

"Some places do not dare to dig deep and strictly investigate problems when they find them, and dare not deal with them quickly and seriously." Even the problems discovered by the national flight inspection team not only did not take advantage of the victory to pursue, but in turn helped to cover the lid, helped to say hello, and did not dare to expose the case, fearing to smear the local party committee and government. On April 22, China Medical Insurance, the competent journal of the National Medical Insurance Bureau, published an editorial entitled "3 Enlightenments Brought to Us by the "Tongji Hospital Incident"".

"It not only distorts the role of fund regulators and fails to be responsible for defending the land, but more importantly, it greatly reduces the power of fund supervision." The editorial of China Medical Insurance went on to mention that "once again illustrates the long-term, arduous and complex work of cracking down on fraud and insurance fraud and guarding the security of funds." ”

Wuhan Tongji Hospital is under the administration of the National Health Commission and is one of dozens of "state-level" hospitals in China, and the pressure to investigate it can be imagined.

What's more, it is difficult to find the consumables implanted in the body. Coupled with the high degree of trust in authoritative hospitals and doctors, whether the consumables are "on the plate" or not will basically not cause patients to suspect.

This time, the consumables manufacturers in the chain of interests provide conclusive evidence and report, which is the key to completing the investigation and handling of the case.

"Stringing consumables, shoddy charging, simple and rude." Some insiders commented, "Strong intentionality, typical insurance fraud." Zhang Qiang, the founder of Zhang Qiang Doctor Group, also believes that it is more difficult to investigate and deal with the fraudulent insurance method of replacing consumables, and hopes that the case is a case. If a similar insurance fraud model is replicated in more hospitals, the cost of medical insurance investigation will be very large.

"Tongji is our benchmark, and this investigation has given all hospitals in Wuhan a warning." The above-mentioned Wuhan medical system doctor told Eight Point Health News.

"I didn't expect it to be so exposed, and I was shocked." A person familiar with the matter said bluntly.

At present, the circular has not yet published information on the inspection and punishment of specific personnel. According to upstream news, during the investigation, the relevant person in charge of the orthopedic department of the hospital has been taken away by the judicial organs. Another source told Eight Points That a retired vice president of Tongji Hospital had been taken away many days ago.

It has been learned that the whistleblower has reported to the Central Commission for Discipline Inspection, and according to the usual practice, the public security department and the Central Discipline Inspection Commission will also have relevant circulars.

Cat and Mouse Game: Administrative Protection and Medical Barriers

Cracking down on fraud and insurance fraud, this sports governance that has been frequently hit hard since the birth of the National Medical Insurance Bureau in 2018, in 2021, this report card will recover 23.4 billion yuan of medical insurance funds, and investigate and punish more than half of the medical institutions for violations.

At the crossroads four years ago, Universal Health insurance was faced with broken governance agencies, high health care costs and the risk of fund bottoming out. In 2018, the employee medical insurance of 106 co-ordination districts and the resident medical insurance of 183 co-ordination districts were not offset in the current period, and the amount of shortfalls was 8.34 billion yuan and 15.4 billion yuan respectively – equivalent to the total amount of medical insurance funds recovered in 2021.

Therefore, it is imperative to control medical insurance fees with fund supervision, volume procurement, medical insurance directory negotiation, and payment method reform as the starting point, while the previous fragmented management authority was handed over to the large medical security bureau in order to form a strong constraint and bargaining power.

Supply and demand determine the bargaining, although the Medical Security Bureau is a super payer with trillions of dollars in hand, but in China's medical service system, public hospitals, and even the top three hospitals still exist as a strong monopoly of the supplier for a long time, they often monopolize regional high-quality medical resources and patient groups, once the medical insurance settlement is stopped, it is easy to cause local livelihood problems.

In addition, the name of the top three naturally has the power of "siphoning" peripheral patients, seeking medical treatment in different places and settling separately in various provinces, resulting in the hospital's dependence on all medical insurance bureaus of all parties is weak, and the power is seriously reversed.

In fact, Tongji Hospital access to Wuhan medical insurance is very late, according to the Yangtze River Business Daily, Changjiang Daily reported that in 2013 Tongji Hospital announced that cardiac and macrovascular surgery became the hospital's first department to enter the Wuhan medical insurance designated department, and the time for tongji to fully access Wuhan medical insurance is 2021.

In addition, the administrative protection capabilities of top three hospitals are also daunting to regulators. Lou Yu, a professor at the School of Civil and Commercial Economics and Law of China University of Political Science and Law, introduced that the so-called administrative protection ability refers to the public hospital's ability to find local health departments and government departments to put pressure on the medical insurance department to obstruct the inspection under the pretext of investigating and punishing fraudulent insurance fraud that will affect medical behavior and damage the hospital's image.

In the daily inspection of the medical insurance department, the chief of the supervision section encounters the director of the public hospital, and his resistance can be imagined. Not to mention the whirlpool of Wuhan Tongji Hospital, its dual identity as a provincial and subordinate.

In a flight inspection of the medical insurance department in 2019, a third-class hospital in a central province and city directly turned off the computer and refused to fly the inspection, and finally was found to be the illegal use of medical insurance funds, with a fine of more than 100 million.

At the same time, the newly established medical insurance departments in various places are not only supervised by public hospitals, but also in the mixed medical parties, and the manpower is often the first to be constrained.

Taking Zigong City in the western region as an example, there are 158 employees in medical insurance agencies and administrative agencies, corresponding to more than 1,300 designated medical institutions, 2,787,900 insured personnel, and an average of 1 staff member to serve more than 17,000 insured personnel, which is very prone to regulatory blind spots.

According to the auditor of the Medical Insurance Bureau of an eastern province, the department has been newly established for three years, the personnel strength is relatively weak, and the clinical professional personnel are lacking. He summed up the law of annual inspections, two weeks in the third-class hospitals, one week in the second-level hospitals, and only one or two days for the community health center to liquidate. "Due to the limited manpower, it is impossible to squat in the top three hospitals every day, and it is longer to intervene in medical behavior."

The medical divide is another powerful moat for public hospitals.

Although the existing inspection team has tried to achieve professional and diversified personnel, many interviewees still said that at this stage, there is still a law to follow in the medical insurance compliance audit, but it involves problems found based on medical experience, and due to the lack of a clear legal basis, the hospital may refuse to recognize.

A commercial insurance practitioner sees this as the divergence between clinical medicine and insurance medicine. The former focuses on the best results, while the latter focuses more on the best price/performance ratio.

In the name of providing the best results, some people unconsciously violate the rules, while others repeatedly probe the edge of the border, looking for management loopholes, and constantly changing dynamically as the anti-fraud campaign deepens.

The two parties that provide services to patients, medicare and hospitals, through different paths, eventually become a "cat and mouse game".

How to regulate the top three?

In the face of the strong third class, the flight inspection initiated by the National Medical Insurance Bureau is similar to the existence of the "Shangfang Sword".

The so-called flying inspection is mostly based on major hospitals and designated medical institutions across the country as the object of spot checks, and enters the scene without prior notice, and this protracted "squeezing water" campaign has expanded from "soft persimmons" such as private hospitals, high-cost groups, and people seeking medical treatment in different places to "hard bones" - local large public hospitals.

The first third to be beaten was Xiangya Second Hospital. In December 2019, the Hunan Provincial Medical Security Bureau disclosed that the hospital had serious illegal use of medical insurance funds such as falsely remembering the cost of consumables such as surgical sutures, excessive examination, and excessive medical treatment, and recovered the illegal medical insurance funds and fined a total of 33.5926 million yuan.

In the same year, a group of flight inspection data of the National Medical Insurance Bureau showed that 39 groups, which lasted 33 days, verified that the amount of fraud and insurance fraud was 260 million yuan, with an average of more than 6 million yuan each time. Its power should not be underestimated. After supervising and inspecting 27 of them, the Health Commission said that although 27 hospitals had irregular behaviors in the use of medical insurance funds, there was no serious illegal "insurance fraud" behavior.

"Illegal use of health insurance funds" or "insurance fraud"? Many industry insiders said that there is a lot of room for flexible interpretation and selective law enforcement.

The Regulations on the Supervision and Administration of the Use of Medical Security Funds, which came into effect in May 2021, are the only administrative regulations in the field of medical insurance fund supervision. Articles 38 and 40 respectively stipulate the treatment of both types of acts, with the former imposing a fine of not less than 1 times but not more than 2 times the amount of loss, and the latter a fine of between 2 and 5 times. The intensity of deterrence, which is lighter or heavier, is self-evident.

No one can accurately interpret it in terms of amount or illegal means. A medical insurance expert pointed out that whether it is intentional is a factor in it, and the above-mentioned commercial insurance person also said that in the case of "grasping the typical", the top penalty will generally be adopted. Tongji Hospital is undoubtedly the "typical" that has been selected.

Also punished in this way is the "sleeve label" of the Orthopedic Department of the Sixth Hospital of Zhengzhou in 2021, with an amount of 1.74 million yuan.

However, the Hainan Provincial Hospital of Traditional Chinese Medicine, the Zhengzhou People's Hospital, and the First People's Hospital of Zunyi City were involved in cases with high amounts of 15.69 million yuan, 9.38 million yuan and 15.58 million yuan respectively, but they were not characterized as "fraudulent insurance" and only recovered the funds involved in the case.

There are also some major amount cases that have not been disclosed in detail, and at a policy briefing in July 2021, Duan Zhengming, deputy director of the Department of Fund Supervision of the National Medical Security Bureau, revealed that the illegal medical insurance fund returned by a hospital reached more than 90 million yuan.

Large public hospitals have cheated larger amounts of insurance, and the way is more hidden, which has almost become a common secret in the industry.

Compared with fines, Lou Yu pointed out that execution cooperation is a means of effective supervision of public hospitals, and the intervention of public security organs can form an effective deterrent.

Behind the "big but not down" is the external public welfare attribute associated with public hospitals. According to many experts, the results of this time have better achieved a balance between protecting people's livelihood and deterrence.

Zhang Qing, a professor at the School of Law and Economic Law of China University of Political Science and Law, pointed out that if some departments with high technical requirements in the top three hospitals have difficulty finding alternative services in the region, considering the clinical treatment needs of most insured persons, it is necessary to use the two means of agreement accountability, namely, termination of agreement or suspension of agreement.

The above-mentioned medical insurance experts believe that the closure of the department is already a retreating choice, and in the Wuhan medical circle with three top-notch medical circles, the suspension of Tongji orthopedic medical insurance services is more to play a warning role.

However, any change is not a cliffhanger. Fund supervision regulations, the "Medical Security Law (Draft for Comments)", the notice of execution linkage have been released one after another, the medical insurance department has more and more guys, and some grass-roots practitioners feel that the work is obviously better to do, "compared with the rough framework of the original "Social Insurance Law", it is now more able to follow the rules."

This year is the fifth year of the "campaign to combat fraud and insurance fraud", and the sports-based governance method will eventually stop, and the process of using medical insurance to leverage medical reform is particularly difficult.

But no matter who we shoot at in the end, we always look forward to a society that pays more attention to fairness and people's livelihood. And in this society, can we not because these gods and immortals fight and hit the fish pond?

Yan Shengnan and Wei Xiaoning | writing

Xu Zhuojun | responsible editor

This article was first published on the WeChat public account "Eight Points Health" (ID: HealthInsight)

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