Breaking through data barriers and safeguarding the security of medical insurance funds

2023-04-11

This big data legal supervision model can quickly detect abnormal situations in medical insurance reimbursement information and timely plug loopholes in medical insurance reimbursement. Recently, the handling prosecutor of the Xi County Procuratorate in Henan Province invited staff from the county's medical security bureau to visit the hospital and introduce the operation of the big data legal supervision model jointly established by several units. The establishment of this supervision model should start with a case handled by the Xi County Procuratorate. On January 5, 2021, while dining at a hotel in Xixian, Hu accidentally fell due to slippery ground, resulting in a patellar fracture. He was hospitalized the next day for treatment. During this period, Hu's husband Ding concealed the fact that Hu fell while dining at a hotel from the hospital, and signed a commitment letter stating that there was no third party responsible, reimbursing 8858.63 yuan from the basic medical insurance fund. In July of the same year, due to unsuccessful negotiations with the hotel for compensation, Hu sued the hotel to the court. Later, the court ruled that a certain hotel compensated Hu with a total of over 88000 yuan for medical expenses and other expenses. In October 2021, a hotel manager learned through other channels that Hu had reimbursed over 8000 yuan of basic medical insurance funds after being hospitalized. After reporting the case, the incident occurred. In April 2022, the public security organs transferred the case to the Xi County Procuratorate for examination and prosecution on suspicion of fraud by Ding. After reviewing the case, the prosecutor found that Ding had already refunded over 8000 yuan of the basic medical insurance fund he had fraudulently obtained after the incident, and there were cases of voluntary surrender and confession of punishment. In June of the same year, the court made a decision not to prosecute Ding in accordance with the law. How is the medical insurance system reviewed when expenses that should have been compensated and paid by others can be easily reimbursed through medical insurance? Are there any loopholes in the medical insurance reimbursement process? The case attracted the attention of the public interest litigation prosecutor of the Xi County Procuratorate, and in response to various questions, the public interest litigation investigators began visiting and investigating. During the visit and investigation, the investigators learned that in actual operation, the Medical Security Bureau will use the commitment letter signed by the actor as the main basis for determining whether they meet the medical insurance reimbursement conditions during the review, and will not conduct on-site verification of the actual situation of the actor's injury. Moreover, there are data barriers between the medical insurance reimbursement system and the judicial agency's case handling system. If the actor intentionally conceals the cause of the injury, Regulatory agencies do not have the technical means to supervise medical insurance reimbursement in a timely and comprehensive manner. In response to this issue, on August 11, 2022, the Xi County Procuratorate issued a procuratorial recommendation to the County Medical Security Bureau, recommending that it promptly improve the basic medical insurance fund reimbursement system, strengthen communication with relevant units such as courts and public security organs, smooth the linkage mechanism of medical insurance claims, and establish information sharing and collaboration mechanisms. After receiving the procuratorial suggestions, the county medical security bureau promptly deployed and carried out special rectification activities for the basic medical insurance fund, requiring designated medical institutions to strictly implement their main responsibilities, strictly pass the initial examination of admission registration, and carry out governance from the source to ensure the normal operation of the basic medical insurance fund. In order to break through the data barriers between the regulatory agencies of the medical security fund and the judicial authorities, the Xi County Procuratorate held a round table meeting in September 2022, inviting units such as the county court and the county public security bureau to negotiate and ultimately reach a consensus. Led by the court, the county court, the county public security bureau

Edit:Ying Ying    Responsible editor:Shen Chen

Source:jcrb.com

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