There are frequent incidents of fraudulent insurance. Where is the boundary of "over-diagnosis and treatment" in medical institutions?

A few days ago, a patient reported that the Second People’s Hospital of Wuhu City, Anhui Province (hereinafter referred to as "Wuhu Second Hospital") overcharged medical expenses, which aroused strong concern in the industry about "excessive diagnosis and treatment".

On December 2nd, Anhui Medical Insurance Bureau informed the Second Hospital of Wuhu about the illegal use of medical insurance funds, and on the 4th, official website of Hunan Medical Insurance Bureau issued the "Administrative Punishment of Xiangya Hospital of Central South University", which fined the hospital about 980,000 yuan for illegal use of medical insurance funds.

CBN found that in recent years, the Regulations on the Supervision and Administration of the Use of Medical Insurance Funds (hereinafter referred to as the Administrative Regulations) and the Interim Measures for the Supervision and Administration of the Use of Medical Insurance Funds (hereinafter referred to as the Interim Measures) and other laws and regulations have been promulgated one after another, providing policy and legal basis for the supervision of medical insurance funds; As a complement to the Interim Measures, the Measures for Reporting Incentives for Illegal Use of Medical Insurance Funds (hereinafter referred to as the "Incentive Measures") was also released in November 2022. This document is to mobilize social forces to participate in fund supervision and safeguard the safety of medical insurance funds.

The National Medical Insurance Bureau has repeatedly stressed that the medical insurance fund will never become "Tang monk meat". According to official data, since 2019, the National Medical Insurance Bureau has sent a total of 184 flight inspection teams to inspect 384 designated medical institutions, and found that 4.35 billion yuan of related funds were used illegally. Since the implementation of the "Incentive Measures" in January this year, medical insurance departments at all levels across the country have verified and recovered the amount of medical insurance violations of 158 million yuan according to the clues reported by the masses.

An expert on medical insurance policy told CBN that with the increasing efforts to crack down on fraudulent medical insurance in China, blatant fraudulent medical insurance behaviors such as "fake patients", "fake services", "fake medical products" and "fake medical insurance expenses" have been effectively curbed, but some fraudulent medical insurance behaviors have also shifted from the front to the back, and gradually changed to behaviors such as excessive medical treatment and excessive fees. How to determine the boundary of excessive medical treatment and how to adopt scientific and accurate comprehensive management methods are the key points in the next stage.

The boundary of "excessive diagnosis and treatment"

According to the notification of Anhui Medical Insurance Bureau, Wuhu Medical Insurance Bureau has fully recovered the medical insurance fund illegally used by Wuhu Second Hospital according to the medical insurance service agreement signed by the hospital, and deducted the liquidated damages at 30%, interviewed the relevant person in charge of the hospital, and handed it over to the public security and health care departments for further verification. At the same time, the bureau has started the administrative punishment procedure in accordance with the Management Regulations.

"Medical insurance service agreements are handled in different ways, but most medical institutions deduct liquidated damages at a rate of 30%." A person in charge of the medical reform department of a health and wellness commission in the southern region told the reporter that in addition to the treatment method according to the medical insurance service agreement, in the administrative punishment procedure, the above-mentioned "Management Regulations" stipulates that illegal acts that cause losses to the medical insurance fund shall be ordered to return, and a fine of more than 1 time and less than 2 times shall be imposed.

Zhao Dahai, a professor at the School of International and Public Affairs of Shanghai Jiaotong University, told the First Financial Reporter that whether it is for medical institutions or medical staff, the end of over-diagnosis and treatment must bring economic returns to themselves and institutions (institutions also involve scale expansion), but in the final analysis, the supervision of medical insurance funds needs a set of strict, scientific and legally effective standards to judge and identify.

"For public hospitals, we can constantly correct their use of medical insurance funds by strengthening supervision, but private hospitals and pharmacies have certain commercial attributes, so we still need to rely on effective supervision methods when avoiding the risk of fraudulent insurance." Zhao Dahai said that in the next stage, health care and medical insurance departments can jointly promote the standardization and implementation of clinical diagnosis and treatment paths.

To this end, the person in charge of the medical insurance service department of a top-three hospital in Beijing said that at any time, medical institutions should never make profits by prescribing drugs and consumables without collecting the information of the insured. This is malicious fraud and insurance fraud, and it is also the bottom line problem. However, at this stage, it is not uncommon for medical institutions to occupy too much medical insurance funds by improving the accessibility of drugs and consumables.

"But whether this belongs to’ excessive diagnosis and treatment’ needs to be viewed objectively." The person in charge said that on the one hand, some innovative drugs are expensive but have great benefits to diseases, and doctors prescribe them for patients out of kindness. However, due to the annual update of the medical insurance catalogue, whether the innovative drugs are still within the scope of the medical insurance catalogue, whether the medical insurance limited payment ratio has been adjusted, and whether the patient’s area is applicable need further careful confirmation. On the other hand, the scope of medical insurance fund’s limited payment needs to refer to a number of matters, including the indications in the drug instructions and the reimbursement ratio of the insured’s location. "It is almost impossible for doctors to record all the contents and ensure that there are no mistakes. Therefore, it is imperative to introduce an information-assisted platform and do a good job in training."

Is there a solution to the problem that medical institutions illegally use medical insurance funds caused by "excessive diagnosis and treatment"?

Cai Haiqing, former director of the Treatment Protection Department of Jiangxi Provincial Medical Insurance Bureau, said that, first of all, it is necessary to solve the problem of how to identify "excessive diagnosis and treatment"; Secondly, with the comprehensive implementation of the reform of DRGs (Payment by Disease Diagnosis Group) and DIG (Payment by Disease Score), the problem of medical insurance payment currently facing the clinic is to solve the problem of "over-diagnosis and treatment" and to prevent possible insufficient diagnosis and treatment. "Insufficient diagnosis and treatment includes low-standard discharge, reducing necessary medical services and inspection items, and reducing the use of drugs and consumables. This situation is to reduce the cost of medical services and improve the yield."

As a matter of fact, the First Financial Reporter learned in the industry that it is difficult to identify, identify and dispose of over-medical treatment. In June this year, "Research on the Identification of Over-medical Treatment Behavior and the Regulation Rules of Medical Insurance" released the first "over-medical treatment index system". The theoretical basis of this system includes sampling data, written materials and written materials of fund supervision discussions of 121 designated medical insurance institutions in Shanghai. It involves 5 first-level indicators, 30 second-level indicators and 67 third-level indicators.

"Although the system is developed in the form of research, it is still some time before it is fully implemented, but at least it has broken the definition of the boundary of overtreatment." Cai Haiqing said.

Regulatory challenges

Since the beginning of this year, official website, the National Medical Insurance Bureau, has published 40 typical cases of fraudulent insurance in four phases. The illegal use of medical insurance funds includes: changing medical treatment items, falsely recording infusion drugs, treatment and inspection fees, forging materials, uploading false medication data, etc. Most of these cases were discovered by local medical insurance departments through active forms such as medical data verification in different places, big data screening and analysis, and on-site supervision and inspection.

On the basis of the previous vigorous rectification work, what are the challenges in the supervision of medical insurance funds and how to establish a long-term supervision mechanism?

To this end, Yu Changyong, an associate professor at the School of Public Administration of Zhongnan University of Economics and Law, told reporters that under the new situation, the new challenges of China’s medical insurance fund supervision can be interpreted from four aspects. First of all, after years of flight inspection and special work to combat fraud and insurance fraud, some "blatant" fraud and insurance fraud in the past have been effectively curbed, and the means of fraud and insurance fraud will be more subtle and the way of fraud will be more complicated.

Secondly, the overall level of medical insurance in various regions has been gradually improved, and the area where patients seek medical treatment has become larger, which will also significantly expand the scope of supervision of medical insurance funds and increase the difficulty of supervision. Thirdly, the reform of outpatient co-ordination makes the medical insurance department not only supervise the hospitalization behavior, but also supervise the outpatient behavior and the drug purchase behavior of pharmacies, and the objects and contents of supervision will show explosive growth.

In addition, the state attaches great importance to the development of Chinese medicine, and Chinese medicine services will be further included in the scope of medical insurance fund payment. However, Chinese medicine services are often treated by people and diseases, and its legal compliance or more difficult to judge, making it more difficult to supervise medical insurance funds.

To this end, Yu Changyong suggested that for some hidden and complicated illegal use of medical insurance funds, the medical insurance administrative department needs to be accurate and qualitative, and administer according to law; On the other hand, it is necessary to increase administrative punishment and even criminal punishment. In addition, it is necessary to strengthen the construction of intelligent monitoring and big data screening mechanisms, and establish a credit supervision system as soon as possible.

For the establishment of a long-term mechanism, a medical insurance fund supervisor said that in fact, in the past, the punishment for illegal use of medical insurance funds was mostly in medical institutions, and the punishment for individuals was not enough; At the same time, due to the low cost of violating laws and regulations, in most cases, it is ultimately handled in accordance with the medical insurance service agreement, and administrative punishment, transfer to justice or discipline inspection are rare.

"On the one hand, it is recommended that the medical insurance department unify the standards for law enforcement and incorporate illegal acts of medical institutions into credit management; On the other hand, medical institutions should establish the accountability system, reward and punishment system for the main leaders of the party and government and department heads, and improve the business training in the field of medical insurance payment. In addition, it is necessary to improve the comprehensive supervision mechanism that pays equal attention to incentives and constraints. Medical institutions that self-examine and self-correct and voluntarily return funds can reduce or not be punished. However, for those medical institutions and individuals who repeatedly check recidivism and do not change, they must be dealt with severely. " The source said.