Recently, the insurance fraud of a hospital in Shanxi Province has attracted a lot of attention after being exposed by the media.
Author: Xu Yucai
来源｜看医界（ID：vistamed）
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Recently, after the media exposed the insurance fraud of a hospital in Shanxi, it once again attracted a lot of attention. Before similar incidents, CCTV also exposed Shenyang insurance fraud, Taihe insurance fraud, at that time had adopted very severe punishment measures, and required all levels and types of medical institutions to carry out special rectification work to combat fraud "look back", but it is unexpected that after several major insurance fraud incidents, there is now such a blatant fraud with fake patients, fake illness, fake hospitalization and other inferior means to carry out insurance fraud in a grand manner, which is really thought-provoking.
So how many moths are attached to the chain formed by the "three fakes" case? Why is this obvious fraud and insurance fraud blatant, fanfare, and repeatedly prohibited, and what is the reason? What is the bottom line that should be guarded as a struggling medical institution? In this article, the author will talk to you about these few questions.
Blatantly defrauding insurance with fake patients, fake illnesses, and fake hospitalizations
According to media reports, the main means adopted by the hospital in Shanxi, which is suspected of insurance fraud, is to "induce some non-sick or mildly ill rural Wubao elderly to be hospitalized in the name of free transfer, free examination, free treatment", etc., after arriving at the hospital, there are many testing items such as "electrocardiogram", "blood test" and "urinalysis" that have not been examined, and there are inflated items and "hanging empty beds" in the process, which are suspected of arbitraging medical insurance funds.
And why would someone take the initiative to "cooperate"? The main people who are hospitalized are the elderly in rural areas, these people not only do not need to spend their own money when they are hospitalized, but also can earn money or get benefits, such as: to "cooperate" people to go to the hospital for treatment, hospitalization not only has a special car, free meals, but also free physical examination, but also can receive rice, noodles, oil and other gifts from the hospital.
How many moths are attached to the insurance fraud chain?
Of course, if it is only a transaction between the hospital and the elderly, I am afraid it will be difficult to make a deal, and even if it happens, it will definitely not be blatant, long-term and repeatedly prohibited, so this kind of behavior must be a chain, and it will form a situation of multi-party participation and common benefits.
Judging from the cases that have been exposed many times, this is indeed the case.
The reporter learned that the hospital mainly looks for the elderly through village cadres, grid workers and directors of rural nursing homes in various villages, and can receive a certain amount of remuneration for pulling heads. In the nursing home, the five-guarantee households are notified by the director to go to the hospital. The old man in the village, who used to be the correspondent of the brigade to contact the five guarantee households to go to the hospital, has now become a grid member responsible for contact, "every time they go, they also have money."
In addition to having money, for these elderly people who go to the hospital, the relevant state subsidies are still there, and they are usually embezzled or appropriated by the relevant personnel or into the pockets of small collectives.
To put an end to it, I am afraid that it is not just a crackdown, but also a rethinking of the medical insurance and welfare system
In fact, in response to this kind of insurance fraud case, the relevant departments have been maintaining a high-pressure situation.
In 2020, the special action to combat fraud and insurance fraud clarified that non-public medical institutions should focus on the treatment of false settlements, inconsistent personnel and certificates, inducement of hospitalization, and hospitalization without indications. In 2021, we will focus on the management of unreasonable charges, collusion of items (drugs), non-standard diagnosis and treatment, fictitious services and other violations, that is, focusing on the "three fakes" such as "fake patients", "fake illnesses" and "fake bills". It has also initially formed the "three combinations" and "five normalizations" of fund supervision, that is, the combination of points, lines and surfaces, promoting the normalization of unannounced inspections, special rectification and daily supervision, the combination of on-site and off-site, promoting the normalization of intelligent monitoring, the combination of government supervision and social supervision, and the normalization of social supervision (reporting and exposure), and the "blatant" insurance fraud of designated medical institutions has been curbed, but the means of insurance fraud have become more concealed and more professional, and fraud and medical corruption are intertwined, and the difficulty of supervision has been increasing.
Not long ago, the National Health Insurance Administration and other four departments jointly issued the "Notice on Carrying out the Unannounced Inspection of the Medical Security Fund in 2024". The "Notice" for designated medical institutions, put forward five key aspects of investigation and punishment, which also specifically proposed to "look back", focusing on whether the problems found in the previous annual inspection still exist and whether the rectification is in place.
Many people in the industry believe that insurance fraud behaviors such as pulling people to fake medical treatment and hospitalization in some hospitals are difficult problems in medical insurance supervision due to their high degree of organization and concealed methods. Some experts believe that the solution should be to improve the supervision of medical insurance funds, and 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.
However, the reason why such insurance fraud will be blatantly banned again and again is probably not enough, and it is indeed worthy of more in-depth analysis. When analyzing the reasons for the decline in the "enthusiasm" of the masses to participate in insurance, some experts put forward a point of view, that is, the "pan-welfare" of the medical insurance system. He said that the so-called "pan-welfare" of medical insurance mainly refers to the special care given by the medical insurance system to certain special groups. According to field surveys in many places, the strongest reaction from the masses is the special care for low-income households and poor households in terms of medical insurance.
He believes that in terms of system, the medical insurance system, the subsistence allowance system and the poverty alleviation system should be independent and should not be tied too much. In particular, you can't let the medical insurance system take care of it at every turn. The medical insurance system solves medical problems and cannot be all-encompassing. The basic logic of the subsistence allowance system is to provide corresponding subsidies to subsistence allowance households so that they can reach the minimum living standard set by the state. Since the low-income households have already enjoyed the benefits of the subsistence allowance system, the medical insurance system should not give them special care. The five guarantees for the elderly and the low-income households belong to the same category, but the five-guarantee is better than the low-income guarantee.
So can we think about the solution to this kind of insurance fraud from avoiding the "pan-welfare" of medical insurance?
It is difficult for the hospital to operate, but it is absolutely not possible to do illegal and criminal insurance fraud
The medical insurance fund is the people's "medical money" and "life-saving money", and the safety of the medical insurance fund has a fundamental impact on the realization of citizens' medical insurance rights and interests, and it is imperative to maintain the safety of the medical insurance fund.
As a medical institution that uses the medical insurance fund, it should become the gatekeeper of the standardized use of the medical insurance fund. Although it is difficult for medical institutions to survive due to various reasons, the loss of public hospitals has a tendency to expand and deepen, and private hospitals are even more difficult, and many hospitals are in a state of closure or semi-shutdown, even if it seems that everything is still normal, the situation is very bad. But no matter how difficult it is, you must not do illegal and criminal things, especially you can't think of crooked ideas, you should work specialization, refinement, and excellence, the so-called "specialization", that is, professionalism, concentration, specialty, and disease; The so-called "refinement" means that it strives for technical excellence, is attractive enough to patients, and has strong adhesion; The so-called "special" means that the technology, management, and service are unique, and there are core competitiveness; The so-called "excellent" means always walking in the forefront of the industry or the local area, and becoming the best and newest one. Always keep innovating: day surgery, rehabilitation, the shortest hospital stay, the least cost, the most scientific management, the lowest cost. Otherwise, it is not a question of whether the hospital is alive or not, but whether the relevant personnel have personal freedom. (This article is published by "Seeing the Medical World", and reprinting must be authorized, and the author and source should be indicated at the beginning of the article.) ）