After the huge insurance fraud case, these issues need to be clarified

As long as the insurance is fraudulent, it is definitely not a "small problem".

The author | Yang Zi

The source | Chinese medical insurance

On the afternoon of April 20, a paper notice unveiled a case of insurance fraud in a third-class hospital with a fine of nearly 60 million yuan: the WeChat public account and official website of the State Medical Insurance Bureau simultaneously released the "Circular on the Special Flight Inspection of the Tongji Hospital Affiliated to tongji Medical College of Huazhong University of Science and Technology", which showed that the State Medical Insurance Bureau, based on the clues of the report, united with the National Health Commission and the State Administration of Market Supervision, conducted a flight inspection of the Tongji Hospital affiliated to the Tongji Medical College of Huazhong University of Science and Technology (hereinafter referred to as "Tongji Hospital"), and 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 in accordance with the "Social Insurance Law of the People's Republic of China" and the "Regulations on the Supervision and Administration of the Use of Medical Security Funds": 1. Order rectification; 2. The hospital self-inspected and voluntarily returned the amount of 19157462.10 yuan to 2 times the amount of the medical insurance fund defrauded 38314924.20 yuan; the amount of fraud found by the inspection was 4186147.54 yuan, and the amount of fraud found by the inspection was 5 times 20930737.70 yuan, a total of 59245661.90 yuan; 3. Ordered the hospital to suspend the medical services used by the orthopedic department for 8 months involving the medical security fund; 4. Transfer the clues of the case to the relevant departments such as public security, market supervision, drug supervision, health and supervision, and discipline inspection and supervision in accordance with laws and regulations.

Within minutes of the announcement, WeChat reads exceeded 10,000 and quickly exceeded the 100,000 mark in the next few hours. The author flipped through the messages on various media platforms and found that most readers, in addition to praising the thunderous means displayed by the medical insurance department in safeguarding the people's life-saving money, were also surprised by why a giant tertiary hospital directly under the National Health Commission, ranked in the top ten in China, and considered by many patients to be the most authoritative in the entire central China region, could defraud such a huge amount. In addition, some "medical insiders" lightly said that the hospital's problem is most likely only a certain type of consumables settlement of the wrong category, not to rise to "fraudulent insurance"; there are also some people who think that the suspension of medical insurance settlement is the "lazy government" of the medical insurance bureau, which can only suffer patients, and there is no benefit; what is more, it is bluntly said that medical insurance should directly pay for the patient's medical expenses, and should not let the hospital "pad" first, and finally the medical insurance has no money to find an excuse "the money of the card hospital is not given, so that the hospital can bear the loss". In view of such key issues, it is necessary for the author to stand up and clarify them for everyone.

01 Financial problems caused by just miscalculation or zeroing?

- Nope! It's fraud!

In fact, as early as April 18, the Wuhan Medical Insurance Bureau issued a relevant announcement, the content of the announcement is not very detailed, only said that "it was found that the orthopedic department of the hospital has the problem of illegal settlement with false consumables product regulation information", which did not cause great repercussions. It is precisely because the announcement seems to be vague that many so-called "insiders" have been given room to guess, thinking that it is just a common small problem of miscalculation or zeroing (such as the dosage of medication is smaller than the minimum package dose, and several patients share the same dose of medicine).

According to upstream news reports, Tongji Hospital uses low-priced materials and charges fees according to high-priced materials, such as 200 yuan for steel plates implanted in the body, but the hospital writes 600 yuan. Not only do patients bear higher costs, but the Medicare Fund loses more.

To the extent of blatantly exchanging consumables, it is obviously an obvious fraud and insurance fraud, with exact subjective intentions, how can it be said to be an "ordinary small problem"?

Some people also think that it may be that the hospital is "kind" to replace the consumables that are not within the scope of medical insurance reimbursement with consumables that can be reimbursed by medical insurance, "more conducive to patients to see a doctor", saying that medical insurance management is only concerned with saving money and disregarding the interests of the insured. The author does not agree with this view. The mainland's medical insurance directory has covered most of the clinical drugs and consumables, but it should be noted that the mainland's current medical resources, economic level and medical insurance resources are still limited, can not afford to squander, medical insurance should also follow the principle of "guaranteeing the basics", in the case of guaranteeing basic medical care, do your best, can not cover everything, everything is guaranteed. Therefore, medical insurance has clear regulations, what can be reported and what cannot be reported, the expenses that cannot be reported can be reimbursed through unreasonable and non-compliant and illegal means, in fact, it is fraudulent insurance. As long as the insurance is fraudulent, it is definitely not a "small problem".

02 Is the suspension of medical insurance settlement for 8 months a lazy government of the medical insurance bureau?

- Nope! It's legal!

On May 1, 2021, the Regulations on the Supervision and Administration of the Use of Medical Security Funds came into effect, filling the gap in the lack of legal support for medical insurance supervision in mainland China. It is precisely in this regulation that those who defraud the medical security fund expenditure shall be ordered by the medical security administrative department to return it and impose a fine of 2 times to 5 times the amount defrauded; the designated medical institution shall be ordered to suspend the medical services involving the medical security fund used by the relevant responsible department for 6 months to 1 year, until the medical security agency terminates the service agreement.

Let's take a look at the exercise of discretion in the result of this penalty: a fine of 2 times the amount of the hospital's self-examination and voluntary return of the amount of the medical insurance fund defrauded; a fine of 5 times the amount of fraud found by the inspection; and an order to suspend the medical services used by the orthopedic department for 8 months involving the medical security fund. Compared with the legal provisions, it is completely reasonable and normal, there is no abuse of power, and there is no laziness in government.

Some people say that it is the insured who ultimately suffers from the suspension of health insurance settlement, so this provision is not reasonable in itself. It should be pointed out that the medical insurance department is the "spokesperson" of the insured, safeguarding the interests of all the insured, but also considering the medical needs of the people, so the suspension of medical insurance settlement for a period of time is a very rare use of a punishment method, unless the case is outrageous, it is a last resort. If you look at the cases handled by the National Medical Insurance Bureau and local medical insurance bureaus in recent years, you will find that the medical insurance department rarely uses this punishment method for the large hospitals that patients often go to, especially the top three hospitals. It can be said that this is also one of the important reasons why the medical insurance department and the large hospital are not dominant when they are in the game. But this restriction cannot be without. In terms of medical insurance, it is necessary to use management methods that are in line with their own functions to form a deterrent to medical institutions, so as to play a role in cracking down on fraud and insurance fraud and protecting the people's life-saving money.

At the same time, the medical insurance department is not punished, regardless of whether the insured is dead or alive. In the circular of the National Medical Insurance Bureau, it is clearly stated that it is necessary to effectively protect the rights and interests of the insured people to seek medical treatment, and during the suspension of orthopedic medical insurance services in Tongji Hospital, orderly guide insured patients to other hospitals for medical treatment.

The author believes that instead of questioning the medical insurance department's compliance with the penalty decision made by the medical insurance department in the comment area of a huge insurance fraud case, it is better to denounce why the hospital cheated the insurance.

03 The Medical Insurance Bureau ran out of money before it began to "shear the wool"?

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With the establishment of the National Medical Insurance Bureau, the mainland's medical insurance governance capacity has made great progress, in recent years, it is rare to hear the news of where the medical insurance fund is going to wear the bottom again, but at the end of each year, there will be people who speculate that "medical insurance has no money" and are more and more debunked.

Although the medical insurance fund is still not rich, under the careful calculation of the medical insurance bureau, the open source and throttling are good: through the collection, drug negotiation and other means to change cages for birds, saving a lot of costs; payment method reform, guide reasonable medical treatment, medical expenses that should not be spent are less; cracking down on fraud and fraud insurance is effective, and recovering a lot of funds... According to the "2021 Medical Security Development Statistical Express", in 2021, the total income and total expenditure of the mainland basic medical insurance fund (including maternity insurance) are 2871.028 billion yuan and 2401.109 billion yuan, respectively, and the cumulative balance of basic medical insurance (including maternity insurance) at the end of the year is 3612.154 billion yuan, with a large balance. The author does not understand, how did this year's "medical insurance no money theory" change from the end of the year to the beginning of the year to start singing?

04 This money should have been reported directly to the patient by medical insurance.

Medical insurance plan to save trouble let the hospital give the people advance money,

In the end, if you don't give it, the hospital is the wronged head.

——Good family work, medical insurance can not even reimburse the money of fraudulent insurance, right?

Under the most ideal model, assuming that all medical items are reasonable, the quality of medical services is high, and the quantity is no more and no less, it is okay for medical insurance to reimburse them without selecting and proportional reimbursement; but everyone knows that this situation is simply impossible in reality. Driven by interests, many medical institutions will prescribe more drugs, do more examinations, and more high-value consumables through the information difference between patients and patients, and seek profits for themselves, while patients have no right to speak. In this case, if medical insurance is reimbursed indiscriminately, it is the people and medical insurance that ultimately suffer, and only medical institutions can get benefits.

In fact, more than a decade ago, the medical insurance department's per-project payment did lead to such consequences, indirectly leading to the rise in medical costs and bringing an economic burden to patients. Therefore, the medical insurance department has changed its management thinking in a timely manner, and through the reform of a mixture of multiple payment methods based on total amount control, it has limited the disorderly income of hospitals, and has also strengthened regulatory measures accordingly. After the patient sees the doctor, the medical insurance must be reviewed to determine whether the medical institution has excessive diagnosis and treatment, whether there is fraud and insurance fraud, the cost of no problem will be allocated in place within a certain period of time, and the cost of the problem will be refused to pay, which will become the price of the medical institution's unruly. It is precisely because of the reform of the health insurance sector that the trend of rising medical costs has been limited.

If this is called "medical insurance to save trouble", it can only be said that the pot that wants to be buckled, there is no excuse for it.

05 Such a large hospital should not covet such a little money from medical insurance,

Large tertiary hospitals will not cheat insurance,

Private hospitals are the main force of insurance fraud.

- Wrong! Insurance fraud does not distinguish between public and private, as long as the insurance fraud is wrong!

Love money is human nature, driven by huge profits, people who can't keep the bottom line really don't necessarily come from anywhere, from 200 yuan to 600 yuan, 200% profits, has reached the standard of Marx's "contempt of the law" in "Capital".

What's more, the amount of insurance fraud in Tongji Hospital is really not "such a little money" can prevaricate in the past. From 2017 to 2020, Tongji Hospital cheated on insurance costs of more than 20 million yuan, which was evenly shared to about 30,000 yuan per day, which was indeed not much compared with the operating income of the entire hospital; but these were the people's money! Isn't it enough to put it on individuals? At the same time, the national flight inspection also found that there are still more than 90 million yuan of illegal expenses in 2021, is it not enough? On the other hand, Tongji Hospital is not without economic strength - the fine of 59 million yuan has now been fully implemented, and the family foundation can be described as rich. This highlights the defraudment of health insurance funds.

For a long time, the trust of the mainland people in the tertiary hospitals was unconditional, and many people believed that only private hospitals would cheat insurance. But this is not the case. Tongji Hospital is not the first public hospital notified by the National Medical Insurance Bureau, and it is likely that it will not be the last. But I hope it's the last one.

The people have given trust, the national policy has given support, and it is still necessary to embezzle the medical insurance fund through fraud and insurance fraud, and the illegal acts of some hospitals cannot be said not to be painful.

Rumors stop at the wise, in the face of fraud and insurance fraud, the total that should be condemned cannot be the legal compliance of the medical insurance department. I hope that more people can polish their eyes, join the team of cracking down on fraud and insurance fraud, and consciously maintain the safety of the fund. (Original title: Regarding the huge insurance fraud case of Huake University Tongji Hospital, there are several issues to clarify)

END

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