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QINGDAO TODAY
在线翻译:
szdaily -> Opinion -> 
Crack down on medical insurance fraud
    2018-12-17  08:53    Shenzhen Daily

Wu Guangqiang

jw368@163.com

ON Nov. 14, China’s Central Television exposed two startling cases of medical insurance fraud. Two private hospitals in Shenyang, capital city of Liaoning Province, had been engaged in schemes to defraud medical insurance funds with false health insurance billings since 2017.

The two hospitals, Jihua Hospital and Shenyang Friendship Kidney Disease Chinese Medicine Hospital, were reportedly found faking patients’ medical records to get medical insurance funds from the government-held public health insurance policy.

Their audacity in deception is shocking. Right after their hospitals were designated as medical-insurance-covered institutions in January 2017, the chiefs found brokers to bring in “patients” and promised to give the brokers kickbacks in proportion with the number of “patients” they brought.

Then came the whole scandal: false patients descended on the hospitals, doctors faked medical cases and prescribed medicine without dispensing it, and false patients were hospitalized for days without any treatment but enjoying free meals. On their “discharge,” each “patient” went home with 300 yuan (US$43) in cash as their kickback.

In this brazen scheme, hospitals, brokers, and “moles” inside the State medical insurance agencies formed a covert alliance of interests, rampantly embezzling State funds, which are also people’s life-saving funds.

Since the fraud came to light, 37 suspects have been arrested or detained and 242 related persons have been investigated. The two hospitals have been ordered to suspend operation for investigation.

However, the cases of the two hospitals are not isolated; they are just the tip of the iceberg. It has been an open secret in many parts of the country that fake hospitalization can make money.

Anning Hospital in Hainan was found defrauding 24.14 million yuan in medical insurance funds from 2009 to 2012 after “hospitalizing” 2,962 “patients.” The hospital enjoyed a “boom” in the three years as with the stolen money buildings for office and wards were erected, medical equipment was purchased, and medical workers’ income rose sharply.

In a hospital in Anshan, Liaoning Province, the chief openly encouraged his employees to defraud the medical insurance fund and instigated his followers to bribe officials in charge of medical insurance. They swindled a whopping 64.1 million yuan by “treating” 17,389 nonexistent patients.

On Jan. 19, Xinhua News Agency ran a lengthy inside story uncovering the horrible scheme concerning the Third Hospital Attached to Anhui TCM University. At this hospital, anyone with a medical insurance card was able to get whatever he wanted; he could decide to see any doctor and make the doctor diagnose whatever “disease” and write whatever prescriptions he wanted. With the medical insurance card of one person, his whole family was able to enjoy all the benefits of health care, illegally.

A black hole is eroding the seemingly massive national medical insurance system, posing a serious threat to the interests of the nation and the people.

According to the data by the Ministry of Human Resources and Social Security, in 2017, the country saw a total income of 1.79 trillion yuan in basic medical insurance fund and 1.44 trillion yuan in expenditure. The medical insurance system has covered 1.35 billion people with 160,000 designated medical institutions and 280,000 drug stores across the country.

The supervision and management of national health insurance systems is a global challenge. Medicare fraud is also a cancer in the U.S. In July 2017, 412 people were charged for defrauding US$1.3 billion with false Medicare billings. The charged defendants included 115 doctors, nurses and other licensed medical professionals who were accused of billing Medicare and Medicaid for drugs unpurchased, collecting money for false rehabilitation treatment and tests, and selling prescriptions, similar practices to those of their Chinese counterparts.

One of the primary reasons for the failed supervision is the difficulty of the job. The fraud is so widespread, covert and collaborative that it is extremely difficult for the watchdog to discover it in the process of the crime. Usually, by the time it is busted, major damage has already been done.

In addition, the supervision mechanism itself is far from satisfactory. Dereliction of duty and corruption in the supervision body often leave the oversight “toothless.” Buck-passing and responsibility-shirking among different agencies further dilutes the potency of the oversight.

Comprehensive measures are called for to effectively curb the rampancy of the fraud. Legislation is needed to severely punish the culprits and AI- and Big Data-based technologies are a must to make supervision more scientific and reliable.

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

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