The recovered funds exceed 16 billion! How do people keep their -medical money–

On the morning of October 22, the National Healthcare Security Administration (NHSA) held a press conference to release the latest version of the Medical Insurance Fund Supervision Blue Book—”Development Report on China’s Medical Security Fund Supervision and Management (2023-2024).” This marks the third time since 2021 that relevant departments have conducted a comprehensive annual review of the regulation of medical insurance funds and published a report on the findings.

What accomplishments have been made in medical insurance fund regulation this year, and what issues have been identified? This year, self-inspection and rectification have been emphasized as crucial initiatives in the healthcare regulatory landscape. What is the significance of self-inspection for medical institutions? What challenges does the current regulation of medical insurance funds face, particularly in light of the demands imposed by advancements in information technology?

This year, 500 institutions underwent flying inspections—surpassing the total from the previous five years combined. According to the latest data from the Blue Book, from January to September this year, various levels of medical insurance departments recovered 16.06 billion yuan from the medical insurance fund, a 38.7% increase year-on-year. Flying inspections have been conducted in all provinces, with 500 designated medical institutions inspected, exceeding the total number from the past five years.

Flying inspections are a vital approach to regulating medical insurance funds, consisting mainly of routine annual inspections and targeted inspections based on specific clues. This year, over 2.2 billion yuan in suspected violations were uncovered through these flying inspections.

Recently, two major cases of fraud were exposed thanks to targeted flying inspection teams dispatched by the NHSA. In September, the NHSA received a tip-off about Wuxi Hongqiao Hospital in Jiangsu Province, suspected of fabricating medical records to defraud insurance claims. Inspectors discovered discrepancies between the timestamps of procedures and the serial numbers of imaging equipment, along with missing manual records and altered data. The hospital’s fraudulent activities have been basically confirmed, and criminal proceedings have been initiated.

Data analysis has also become an important source of leads for flying inspections. In August, the NHSA’s data center detected unusual purchasing patterns in a pharmacy in Harbin, Heilongjiang Province, where 96 insured individuals made extraordinarily high purchases; one had spent over a million on medications in two years. Subsequent inspections revealed that four pharmacies were involved in widespread forgery of special drug prescriptions, aiding illicit trade in medical insurance drugs, totaling over 100 million yuan. Law enforcement agencies have since launched investigations into this case.

Beyond flying inspections, self-inspection has become increasingly significant in oversight. The Blue Book indicates that to date, medical institutions have voluntarily returned nearly 36.2 billion yuan to the medical insurance funds through self-checks, three times the amount identified as illegal during national flying inspections this year. So, what is the significance of this self-inspection initiative?

According to Yan Zhen, Executive Dean of the National Medical Security Research Institute at Capital Medical University, self-inspection and rectification are crucial. They foster consensus and lower regulatory costs. The healthcare insurance system often involves cities with populations ranging from over a million to several million, yet the number of regulatory staff can be quite limited—sometimes around ten.

The voluntary return of over 36 billion yuan can be attributed to the deterrent effect of regulatory oversight—creating a sense of urgency among healthcare institutions, highlighting that oversight is a serious matter. It also encourages healthcare institutions to engage actively, recognizing that fraudulent actions are not always sanctioned by management, possibly stemming from a few individuals’ actions. Thus, self-inspection activates institutional accountability.

What challenges does the regulation of medical insurance funds currently face? With increased scrutiny and evolving regulatory models, certain challenges persist. The Blue Book outlines several key issues:

1. Growing pressure on the sustainable operation of medical insurance funds.
2. Inadequate legal frameworks for fund regulation and insufficient regulatory manpower and capabilities.
3. Changes in medical insurance fund usage due to policy adjustments.
4. The dual nature of technology in regulation.
5. The escalating tug-of-war between regulators and those being regulated.

Thus far this year, 111 fraudulent institutions were identified based on leads from big data models. Of the more than 2.2 billion yuan in suspected violations uncovered through flying inspections, approximately 800 million came directly from data-driven intelligence. However, the sophistication of information technology has made fraudulent activities even more obscure and complex, raising the stakes for regulatory demands.

Yan Zhen noted that non-compliant actions by medical institutions have become more secretive and varied, necessitating robust oversight mechanisms. Instances like multiple healthcare cards used concurrently at one location can serve as red flags for detection.

Looking ahead, where does regulation of the medical insurance fund go from here? What steps will be taken to address these issues? The NHSA addressed these points in the press conference.

Xie Zhangzhu, Deputy Director of the Fund Regulation Department of the NHSA, stated that the agency will expand the scope of flying inspections, particularly increasing the number of checks on high-risk institutions suspected of fraud. The agency will ensure thorough reviews in cases of fund deficits, delayed settlements to medical institutions, sluggish progress on traceability for medications, and inadequate local inspections.

Additionally, an incentive and accountability mechanism will be established for self-inspection measures to promote genuine commitment to rectification among healthcare institutions. There will be a continual strengthening of big data surveillance focused on false diagnoses, fake prescriptions, and illegal trade in medical insurance drugs. The data will be used to flag suspicious activities and guide local authorities in their investigations, ensuring rigorous enforcement against fraudulent practices.