The whole village suffers from "cerebral stroke"? Local medical insurance management needs a "remedy".
[4] Compiled from: Red Star News
Case review
Recently, some citizens reported to China National Radio that in Cuikou Village, Laihe Town, Shan County, Shandong Province, most villagers' urban and rural resident medical insurance accounts have inexplicably shown multiple medical insurance settlement records for stroke over the past five years. A child as young as five had a stroke settlement record, and an elderly person who had been deceased for a long time still had 48 medical insurance consumption records...
After a preliminary investigation by the joint task force, between 2016 and 2019, village clinics in Shan County were required to use the "Shan County Primary Medical Institution Management Information System" when treating patients. According to operating procedures, village doctors had to first record disease information before issuing prescriptions, and could enter disease information either by disease code or by the first letters of the disease name in pinyin. Village doctor Zhu Mouju did not follow the operating standards to accurately input the correct disease names. To save time and effort, she simply used methods like double-clicking the spacebar to default to "stroke" with disease code "0001" as the disease information, causing a large number of villagers to be labeled as having "stroke." Currently, the verified erroneous information has been corrected.
Additionally, village doctor Zhu Mouju, driven by greed, engaged in the act of fabricating treatment records to fraudulently obtain funds from the residents' basic medical insurance outpatient coordination fund. Each fabricated treatment record allowed her to embezzle 5 yuan in consultation fees. From January 2016 to September 2021, over nearly six years, the clinic had a total of 49,633 treatment records, involving a total amount of 564,395.29 yuan, with actual reimbursements from the residents' basic medical insurance outpatient coordination fund totaling 376,968.03 yuan (including 248,165 yuan in consultation fees and 128,803.03 yuan in medication costs). The largest single treatment fee was 50.2 yuan, with an actual reimbursement of 27.1 yuan; the smallest was 1.84 yuan, with an actual reimbursement of 0.92 yuan.
On October 19, the Shan County Public Security Bureau, based on the investigation findings, lawfully detained village doctor Zhu Mouju on suspicion of fraud.
"Criminal Law of the People's Republic of China"
Article 266 [Fraud Crime]
Whoever defrauds public or private property, if the amount is relatively large, shall be sentenced to fixed-term imprisonment of not more than three years, criminal detention, or public surveillance, and shall also, or shall only, be fined; if the amount is huge or there are other serious circumstances, shall be sentenced to fixed-term imprisonment of not less than three years but not more than ten years, and shall also be fined; if the amount is especially huge or there are other especially serious circumstances, shall be sentenced to fixed-term imprisonment of not less than ten years or life imprisonment, and shall also be fined or have property confiscated. Where this Law otherwise provides, such provisions shall prevail.
[1] The author's perspective
This case not only reveals lax supervision of the medical insurance system in Shan County but also the harm to the interests of the affected villagers, with far-reaching consequences that cannot be ignored or concealed.
First, using a medical insurance card to see a doctor and get medication requires the cardholder to present the card for identity verification. So how did this clinic manage to settle payments uniformly with medical insurance cards without the villagers' knowledge? Was the relevant identity verification process merely a formality, or was there a more serious issue of identity information theft? Notably, the local medical insurance department stated that the medical insurance bureau only reviews the medical insurance settlement data reported by township health centers each month, without specifically reviewing the relevant data from village-level clinics, which is left to the township health centers for review. In other words, not only is there an issue of delegated authority, but the review itself is only general and not detailed for each transaction, making such a disaster somewhat "understandable."
Secondly, for those villagers who were "diagnosed with stroke" out of nowhere, the sudden addition of a stroke condition will inevitably affect their normal lives. For instance, purchasing insurance and filing claims will certainly become more difficult, and their children's school admissions or employment may also face certain obstacles. Thus, this could be a stain affecting their entire lives.
In the face of such egregious illegal acts, the relevant authorities need to investigate the matter as soon as possible to provide an explanation to the public, clarify where the defrauded medical insurance funds have gone, and promptly remedy the flawed supervision system to minimize the impact. On issues closely related to people's livelihoods, the relevant departments should stay vigilant, remain alert, ensure that every violation is investigated, and enforce the law strictly, lest they, like those poor villagers, suffer a "stroke" without even realizing it.
