Who is mad to eat ** "help money"?

Since the implementation of the new medical reform in China, the basic medical insurance system consisting of the three systems of medical insurance for employees, medical insurance for residents and the new rural cooperative medical system has made a great contribution to the popularization of people's livelihood. However, the medical insurance model of “dividing the cooking at different grades” by geographical units has caused differences and loopholes in the collection and use of local medical insurance funds. A half-month survey of reporters found that behaviors such as fraudulent insurance, fraudulent claims, swiping cash, or shopping are frenziedly eroding health insurance funds.

Medicare fraud insurance has formed a black industrial chain At the beginning of this year, only the villager Xiong of the junior high school culture in Tongcheng County, Hubei Province, took a seat in Hunan Yueyang County Court. Prosecutors alleged that Xiong had forged information on hospitalization in Shanghai Changhai Hospital and Eastern Hepatobiliary Surgery Hospital. He had defrauded rural cooperative medical care compensation in a total of 14 cases in multiple places, involving a total amount of 92,000 yuan.

Half-monthly talks The reporter learned from some local prosecutors that the new rural cooperative medical system is a high-risk area for criminal fraud in recent years. Among them, there are people who report false accounts, but some townships and villages have cadres who have taken in and transferred funds from the participating officers or have issued false certificates to help others defraud medical compensation funds; the new rural cooperative agency has fabricated, inflated, concealed, withheld, and concealed. Transferring funds and misappropriating funds, as well as fixed-point medical institutions making up fake medical records and fake prescriptions, replacing low-priced drugs with high-priced drugs, or extending hospitalization time to withdraw funds.

In cities, the “moral hazards” faced by urban residents' medical insurance and employee medical insurance are increasingly prominent. In 2013, 18 hospitals in Changsha, Hunan Province were investigated for the existence of “surveillance of hospital beds”. In February of this year, some people also reported that the doctors of Changsha Wangchengpo Hospital paid their own pockets to senior citizens for “inpatient treatment”. They only needed to provide medical insurance cards, and they could receive 200 yuan “rewards” four days after being hospitalized. An old man who was hospitalized in the hospital Humou revealed to reporters that during hospitalization he seldom went to the hospital, but every day he had a list of “taking medicine, taking injections, checking treatment items”, and the cost of a single hospital stay was a few thousand dollars. .

The disguised form of the medical insurance card is a commonly used method of capturing “life-saving money” in the city's pharmaceutical business field. Reporters surveyed in many places found that the transformation of the medical insurance card into a shopping card has become an open secret. Toothpaste towel skin care products, longan cuttlefish olive oil, tobacco and tobacco tea chocolate and other large and small commodities can be purchased in the pharmacy brush Medicare card, some products can also enjoy 10% discount for medical insurance card.

Some Medicare-designated pharmacies have opened "non-pharmaceutical areas" to induce individual participants to use Medicare personal accounts for other purposes. When an individual's account has no money to pay for when he is ill, these insurers will find ways to stay in hospitals and use pooled funds to put the overall health insurance fund at risk.

Hanging bed fraud insurance repeatedly penalties, supervision is like "tickling"

What are the consequences of the hospital being found to be hospitalized? An industry source told reporters half-monthly: Do not be afraid, the sky will not fall. For example, in a hospital with such serious violations, the punishment given by the local health department was “stopping the medical insurance service qualification for one month and impose a corresponding fine”.

Some grassroots medical insurance bureau staff introduced that the medical insurance supervision of the employees lacks legal and policy basis, which is mainly based on the medical service agreement, leading the regulatory authorities to find that the hospital has “invited people to stay in hospital”, illegally tying up the bed, minor diseases and major violations. The penalty content is mainly the suspension of the hospital health insurance payment agreement. Due to the low cost of violations, many hospitals have made repeated offenses.

A staff member of the Central Province Medical Insurance Bureau frankly stated: “The hospitalization of the patient needs to meet the indication of hospitalization, and the right to be identified is in the hands of the doctor. We can only examine whether the per capita hospitalization cost in the hospital has exceeded the standard, what drugs the doctor prescribed, and what to do to check these. With professionalism, we cannot judge or manage."

“A lot of participating farmers have to work outside the country and need to be reimbursed after participating in medical treatment. However, there is a loophole in the regulation of reimbursement for reimbursement from different places. The medical insurance departments in various places have not achieved networking.” A health department head of the labor force export market said, “General auditors Only medical experience can be used to infer the authenticity of data from other provinces, including the list of hospitals and the need for pathological treatment, etc. In addition to the limited number of reviewers at the county-level Peasants' Cooperative Office, staff from other medical institutions in the country will collaborate with unscrupulous individuals and use fraudulent materials to defraud. , inspection is more difficult."

From the perspective of “hospitalization cash” and other acts, the creation of medical records, prescribing, and treatment must involve the full cooperation of relevant personnel in hospitals and even regulatory agencies. Some experts pointed out that as long as they participate in sub-fertilization of "Ghosts" to do tricks, cash out and other short-selling medical insurance funds will be intensified.