The rural five-guarantee elderly mainly refer to the elderly in rural areas who are old and frail, have no children, or are unable to support their children. They are hospitalized and hospitalized by the state.
The reporter recently interviewed in Fenyang City, Shanxi Province, and found that the local Hospital for the Disabled Chinese Medicine induced some rural five-guarantee elderly people with no disease or mild symptoms to be hospitalized in the name of free transfer, free examination, and free treatment.
At present, the Fenyang Municipal Public Security Bureau has filed a case to investigate the case, and the relevant responsible persons have been taken criminal coercive measures.
The elderly in rural areas were dragged to fake medical treatment and hospitalization
"Car pick-up and delivery, food and lodging, free examination, free hospitalization, free treatment and ......" In Jicun Town, Fenyang City and other townships, many elderly people with five guarantees have had the experience of being hospitalized in the Hospital for the Disabled.
Disabled Chinese Medicine Hospital. Xinhua News Agency (photo by Yang Zhe on April 29)
Founded in 2020, the Hospital has 28 medical staff and 48 beds.
According to clues, the reporter got a list of 42 elderly people who had been treated in the hospital. The earliest hospitalization time for the elderly in the list is February 2023, and the elderly with the most hospitalizations have been hospitalized 4 times since last year. The reporter selected more than a dozen of them to visit one by one.
Recently, the reporter accompanied a rural elderly man to the hospital for treatment, and only carried out three simple examinations of pulse, blood pressure, stethoscope and heart, and the doctor gave the diagnosis of "need for hospitalization" in less than 10 minutes. The old man was then taken into a seven-person ward for infusion and a bag of medicinal decoction.
After that, on the old man's "one-day list of hospitalization expenses" that day, a number of tests such as "electrocardiogram", "blood test" and "urinalysis" appeared out of thin air, costing a total of 1313.86 yuan. "The actual inspection is only about 300 yuan." An insider revealed.
The one-day list of the expenses of an elderly person who was hospitalized in the Chinese Medicine Hospital for the Disabled added some diagnosis and treatment items out of thin air. Photo by Xinhua News Agency reporter Li Ziyi
There are several other elderly people in this inpatient ward who are receiving infusions. Although their physical conditions are different, the process of medical treatment is almost the same: they are induced to come in the name of "free examination and free treatment", and they are picked up by special car, and they come for infusion after simply asking. ”
Some elderly people with five guarantees reported that they received several notices that they were going to the hospital for "hospitalization", but after arriving, they were told that they did not need to live, and they went to the same day and returned on the same day, and the hospitalization expenses were still recorded in their names.
Li Hu, a 71-year-old villager from Chengzi Village, Jicun Township, was invited to the hospital for a check-up on February 8 this year and was told to be hospitalized. However, "blood was drawn, an electrocardiogram was done, and he was sent back to the village the same day." He remembers very well that on that day, a total of 6 Wubao elderly people in the same village, including him and Zhao Rugao, were taken to the Disabled Chinese Medicine Hospital, and each received a bag of 10 catties of rice and a pot of 5 catties of sesame oil from the hospital.
Gao De, an elderly person in Xinghua Village and Township Nursing Home, also had the same experience last summer. "I set off in the morning, and it was already 11 o'clock when I arrived at the Disabled Chinese Medicine Hospital, and I had a meal at noon, and I came back by car in the evening." He said.
The reporter inquired through the national medical insurance service platform and found that Li Hu had a record of hospitalization from February 10, 2024 (the first day of the first lunar month) to February 17, 2024, and the medical insurance reimbursed 5456.72 yuan. The hospitalization period under the name of HD De is from June 28 to July 5, 2023, and the total reimbursement of 8-day medical insurance is 4296.14 yuan.
Pull people to eat kickbacks, medical insurance fraud into business
"Ordinary people need to pay the amount below the medical insurance threshold and the amount beyond the reimbursement ceiling in the medical insurance reimbursement catalog; When the five insured households are actually hospitalized, the medical expenses borne by the individual are guaranteed by medical assistance, and there is no deposit before hospitalization, and no penny is spent on discharge settlement. An executive of primary medical insurance reimbursement said.
Some elderly people who have been "hospitalized" in the Hospital for the Disabled said that they have special car pick-up and drop-off and free meals when they go to the hospital for medical treatment and hospitalization, and they have no personal expenses from beginning to end, and they can also receive gifts such as rice, noodles and oil.
"It doesn't cost us a week or a few days." Zhao Weilu, a 69-year-old man from Chengzi Village, Jicun Town, said: "I stayed three times last year, once this spring, and plans to stay for a few more days in the summer." Wang Hezhong, a 70-year-old man in Tangxingzhuang Village, Jicun Town, said.
The medical insurance reimbursement record of a certain five-guarantee elderly person in the Disabled Chinese Medicine Hospital queried on the national medical insurance reimbursement platform will be hospitalized 3 times in 2023 and 1 time in the spring of 2024. (Puzzle photo) Xinhua News Agency (photo by Yang Zhe)
Industry insiders said that patients who were registered for hospitalization without hospitalization are commonly known as "hanging empty beds", that is, fake hospitalization, which is medical insurance fraud.
How did these five-guarantee elderly people get "locked in"?
The reporter learned that the Disabled Health Traditional Chinese Medicine Hospital mainly looks for the elderly through the village cadres, grid members and directors of rural nursing homes in various villages, and can receive a certain remuneration for pulling people's heads. "The three five-guarantee households in our nursing home were all notified by the director to go to the hospital." Gao Gao De said that the dean let him go.
Zhao Weilu told reporters that in the village, the brigade correspondent used to contact the five guarantee households to go to the hospital, but now it has become a grid member responsible for contact, "every time they go, they also have money."
The reporter contacted a grid member in the village, who admitted that he had organized more than 20 elderly people in the village to go to the hospital for examination and treatment, "The salesman of the hospital found me, and I asked them to go to the Hospital for the Disabled Chinese Medicine to be hospitalized, and they all believed what I said." ”
The grid worker had already known about the situation of strangers entering the village to contact the five guarantee households, but denied that he had made a profit from it, saying that he had not received the "referral fee" from the Disabled Chinese Medicine Hospital. But when the reporter asked whether he could cooperate as a salesman of a private hospital in the provincial capital, the other party said, "You can cooperate, and you can see how much money you give."
A hospital insider told reporters that the hospital has a special person responsible for the search and contact of the elderly in the five guarantees, and they will pay the contact person in each village or nursing home according to the "capitation fee" standard of 600 yuan per person.
It is necessary to form a joint force to strengthen the attack
After a preliminary verification by the public security department, Fenyang Disabled Health Traditional Chinese Medicine Hospital picked up special people from local rural areas to the hospital for hospitalization in the name of regular physical examinations, and provided free meals during hospitalization, and the investigation records of 8 people did not match the hospitalization situation shown by the medical insurance system. The hospital was forced to carry out a self-inspection and handed over the amount of medical insurance used in violation of regulations of 197601 yuan to the medical insurance supervision department on May 2.
A number of people in the industry believe that the National Health Insurance Bureau and other departments have carried out special rectification of medical insurance fraud for many times, and it is a difficult problem in medical insurance supervision to pull people's heads, fake medical treatment, fake hospitalization and other insurance fraud behaviors such as pulling people's heads, fake medical treatment, and fake hospitalization in the disabled Chinese medicine hospital.
According to industry insiders who have participated in the unannounced inspection of the medical insurance bureau, the hospital can forge a series of medical treatment materials such as medical records, coded lists of drugs and consumables, and charging documents that meet the reimbursement of medical insurance. During the on-site inspection, even if the dean, doctor, or patient are approached, if these people are involved, they will not tell the truth.
According to the staff of the local medical insurance department, there are many hospitals and township health institutions to be supervised by the current medical insurance fund, and the amount of funds is huge.
The reporter learned that modern information technology means such as intelligent audit, intelligent monitoring, and big data supervision have improved the accuracy and effectiveness of supervision to a certain extent. However, industry insiders said that big data screening mainly depends on whether the hospital's diagnosis and treatment behavior exceeds the list of medical insurance drugs, diagnosis and treatment items, and the catalog of medical service facilities, and whether there are excessive inspections and excessive prescriptions, which are difficult to find violations such as inducing hospitalization.
Xing Yuan, a professor of sociology at Shanxi University, and other interviewed experts believe that to improve the supervision of medical insurance funds, it is necessary to change "finding problems and punishing them afterwards" to "moving the regulatory threshold forward and giving early warning"; Adhere to the combination of traditional and modern supervision methods, and make full use of verified and effective big data models to screen and analyze emerging problems, tendencies, and trends; Complete mechanisms for data sharing, mutual transfer of leads, and joint investigation and joint office of departments such as for medical insurance, public security, and finance, strengthen joint disciplinary action, and promote industry governance.
Source: Xinhua Vision