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在线翻译:
szdaily -> Opinion -> 
Fighting health care fraud
    2015-09-07  08:53    Shenzhen Daily

    Wu Guangqiang

    jw368@163.com

    THE New Rural Cooperative Medical System (NRCMS) introduced in 2003 was designed to make health care more affordable for farmers, the poor in particular, across China’s vast rural areas who otherwise, without medical insurance coverage, couldn’t afford treatments for minor illnesses, let alone major ones.

    In 1998, a mere 9.5 percent of the entire rural Chinese population had medical insurance, but by the end of 2010, the system covered almost all of China’s rural residents. Today, after several adjustments, each beneficiary of the system is entitled to annual subsidies of 320 yuan (US$50) for health care plus reimbursement of up to 75 percent of hospitalization expenses.

    Even though the coverage is still low, most farmers see the funds as “life-saving money,” which satisfies their basic health care needs.

    However, a recent media investigation uncovered a massive medical insurance fraud scheme in some rural parts of China’s southwestern province of Guizhou.

    An investigation of 135 medical institutions designated as NRCMS pilot units showed that 107 them were suspected of being involved in defrauding NRCMS funds, accounting for 76.30 percent of the probed institutions.

    The inspection of 41 institutions in the city of Anshun revealed that all of them were suspected of fraud scandals.

    There are numerous individual swindlers, but the major offenders are the medical institutions themselves.

    There is a dazzling variety of tricks to swindle the money. A private hospital collected farmers’ IDs and residence permit cards and made up false medical records to receive insurance money. More commonplace means included the augmenting of expenses by increasing hospital stays, charging for nonexistent surgeries or medications or excessive/unnecessary prescriptions or equipment use. A minor cold could end up costing hundreds or even thousands of yuan.

    Some hospitals offered “free” checkups for farmers, plus free food and pickup, but their purpose was to make use of those with diseases to squeeze as much money out of insurers as possible.

    The uncovered scandals are only the tip of the iceberg — health care fraud is a pervasive problem in China, not only for the NRCMS but also the system serving urban residents.

    And China is not alone. According to the data by America’s FBI and health care authorities, the federal health insurance system suffers a minimum loss of US$60 billion each year because of fraud.

    The fundamental cause of the massive health care fraud is the existence of loopholes in the health care system and in the law, which are exploited by parasites inside and outside the medical system.

    In China, so far, there is no law specifically to combat health care fraud, and related regulations and standards are far from effective, leaving most offenders unpunished or at most gone with a slap on the wrist. This serves as a reward for the offenders.

    

    There is an apparent lack of supervision and regulation for health care fraud. Currently, the only oversight comes in the form of expost audits. Surprise and on-site inspections are auxiliary and random.

    Of course, effective supervision means huge investments of money and manpower; however, the State is losing money through fraud anyway.

    To effectively curb the rampant fraud, health care fraud must be criminalized. Any offender must be punished according to the nature of the offense.

    A joint force consisting of health care authorities, the police, finance, commercial and tax authorities and the justice department should carry out coordinated operations based on a well-devised procedure.

    Every medical institution, including private ones, should establish a supervisory system. Any instances of fraud should lead to sanctions such as warnings, demerits, demotions, dismissals and criminal penalties.

    Only when each unruly medical worker faces real consequences can health care fraud be effectively curbed. Firm determination and practical measures from the authorities are the keys to success.

    (The author is an English tutor and freelance writer.)

    

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