Recently, the National Medical Insurance Administration discovered through big data screening that some hospitals have provided “prostate MRI” and “free prostate-specific antigen tests” for female patients, while other hospitals have performed “hysteroscopy,” “cervical cancer screening,” and “cervical dilation procedures” for male patients.
Among these bizarre tests and treatments, some are due to medical institutions indiscriminately ordering tests for revenue, others are due to unreasonable packaged charges, some stem from medical staff’s templated prescriptions to extract insurance funds, and some involve insured individuals lending their medical coverage vouchers to others to seek medical care under false pretenses. Ultimately, this reflects a few hospitals and doctors treating health insurance as a “cash cow” and trying all means to extract benefits from it.
It is noteworthy that 30 hospitals were reported for “providing gynecological services to male patients” and “providing urological services to female patients,” with the hospitals at the top of the list conducting bizarre tests 1,674 and 1,263 times in a year, respectively, with some hospitals appearing on both lists. This not only indicates a high frequency of such issues but also reflects that some medical institutions are brazen and unscrupulous, reaching the point of blurring the lines between male and female services.
Why is this happening? The National Medical Insurance Administration explicitly pointed out in the report that it is “insurance fraud.” In recent years, schemes to defraud health insurance have become more diverse, with various fraudulent behaviors showing characteristics such as “many stakeholders, broad involvement, covert methods, and clear organizational features,” therefore, regular oversight must be strengthened, and comprehensive systems must be implemented to ensure the security of health insurance funds.
Especially in the digital age, utilizing big data to promptly identify problem clues has become a powerful tool for regulation. In May 2023, the National Medical Insurance Administration published the “Intelligent Review and Monitoring Knowledge Base and Rule Base Framework (Version 1.0),” clarifying the knowledge base and rule base, and through an intelligent monitoring system, moving the regulatory checkpoints forward to automatically intercept “clearly violating” behaviors and alert “suspicious” behaviors that violate reasonable use rules.
These bizarre tests where “gender is indistinct” were discovered through big data screening, and health insurance departments nationwide have conducted a thorough verification of the problem clues issued by the National Medical Insurance Administration as per unified deployment. The net of regulation is vast and thorough, and before big data, the bizarre tests of “gender-indistinct” will eventually have nowhere to hide.
On the other hand, there should also be increased accountability and penalties for illegal behaviors, making related hospitals and responsible individuals pay the necessary price. The national meeting on deepening the rectification of health insurance fraud held on July 30 emphasized increasing exposure efforts, enhancing the relevance of exposing typical issues, and fully communicating a “zero tolerance” attitude towards fraud.
This time, the National Medical Insurance Administration has directly named which medical institutions and which doctors are violating regulations, clearly listing them in a table. Public disclosure, serious accountability, and penalties directed at individuals are essential to create a strong deterrent effect.
Health insurance funds are the “medical money” and “lifesaving money” for the public, and every cent cannot be infringed upon. According to a relevant responsible person from the National Medical Insurance Administration, the cumulative surplus of the employee health insurance fund in 2023 is 2.6 trillion yuan, which may seem substantial, but since it must be used to ensure the protection of retired workers, a reasonable scale must be maintained; the cumulative surplus of the resident health insurance fund has exceeded 760 billion yuan, still in tight balance.
Because health insurance funds still require “careful budgeting,” it is even more imperative to strengthen regulatory barriers, allowing no room for any waste or embezzlement, and preventing any institution or individual from engaging in shady dealings with it, ensuring every penny is used effectively.
