In -depth thinking | The liability for liability for the liquidation of the medical insurance agreement and its anti -fraud function

According to data from the National Medical Insurance Bureau, in 2021, medical insurance institutions checked 708,000 designated pharmaceutical institutions, investigated 411,000 yuan, and recovered 23.4 billion yuan in medical insurance funds. The problem rate accounts for 58%, and an average of nearly 57,000 yuan per medical institution occupies or defrauds the medical insurance fund. The phenomenon of illegal occupation or cheating the medical insurance fund is more severe. Medical insurance inspections and law enforcement are of great significance to curb the illegal behavior of the medical insurance fund, but due to the impact of multiple factors such as the concealment of the medical insurance fund of the medical institution, it is necessary to take wider fund supervision measures. The default clause in the medical insurance agreement signed with the designated medical institution has an important curb function for the illegal behavior of the medical insurance fund of the medical institution, and it should pay full attention to it.

Medical Institutional Medical Insurance Fraudida Hiddenness

Basic medical insurance relations involve three parties in medical, insurance, and affected. Based on the status of medical institutions in medical, insurance, and affected three parties, and the characteristics of medical institutions, medical institutions have the significance of "doorkeeper" for medical insurance funds. As the direct use of the medical insurance fund, the medical institution has a key position in the control of medical insurance funds due to its professionalism. Therefore, the medical insurance control fee is mainly to control the medical insurance cost of medical institutions. The illegal acts involving medical insurance funds involved in medical institutions, especially medical insurance fraud, are the key containment and crackdown on medical insurance fees. If the "doorkeeper" duty of the medical institution is lost and even participating in medical insurance fraud, it will cause major losses of the medical insurance fund , And significantly increase the difficulty of investigation and punishment of fraud. Compared with other medical insurance fraud, medical insurance fraud implemented or participated in medical institutions is more concealed.

Medical Insurance Fund and its administrators are the main objects of victims of medical insurance fraud, but they are not parties to medical insurance fraud. Improper behaviors of medical institutions such as excessive examination, decomposition prescription, over -drug prescription, repeated medicine and other difficulties are difficult to directly. Feel and identify. Although regulators can timely find that medical institutions can be found in time through intelligent monitoring and other means to incorporate illegal activities such as medical insurance expenses that do not belong to the scope of medical security funds. Behavior, but with the "renovation" of fraud, the crime methods are more hidden, and technical means are difficult to effectively monitor. Because such violations of laws and regulations are mostly involved in the facts of diagnosis and treatment and medication, intelligent monitoring is difficult to competent, which greatly increases the difficulty of discovery. In addition, due to the professionalism of medical services, it is difficult for patients with insured patients to discover the improper or fraud behavior of medical institutions, and they cannot report complaints such as agencies. In March 2022, the National Medical Insurance Bureau combined with the National Health and Health Commission and the General Administration of Market Supervision in accordance with the report clues to conduct a flight inspection of a well -known top three hospitals in Central China. It was found that from January to September 2020, the hospital had a problem of high -value medical consumables in the hospital's high -value medical consumables, and deceived the medical insurance fund to pay more than 200 million yuan. If there is no reporter report, it is difficult to find the fraud problem in the intelligent monitoring or the general inspection.

The identity recognition problem arising from the insured person to enjoy the treatment of medical insurance depends on the identity review of the medical institution staff. If the doctor knows that the patient is caused by the damage of the third party, but disregard or even participate in the "operation" and be used as a general diagnosis and treatment, it will lead to a large loss of medical insurance funds. The loss of such "doorkeeper" duties in medical institutions is also concealed, and it is difficult to discover intelligent monitoring and ordinary inspection.

The cost of law enforcement in medical insurance fraud behavior in medical institutions is large

The concealment of medical insurance fraud in medical institutions has led to an increase in difficulty in investigating and punishing such illegal, illegal, and breach of contract, and the cost of law enforcement is higher. The main reason is from two points:

First, the requirements of administrative penalties are high. At present, administrative penalties are mainly implemented on such illegal and illegal acts, and according to administrative penalties, whether it is procedural requirements such as inspection, notification, hearing, punishment, or the sufficientness of evidence, and the factual requirements of the facts of the facts are high. Due to the judgment of the subjective status of the perpetrator, the medical institutions and their staff subjectively know the illegal and illegal acts and deliberately pursue or let the laws of violations, and then implement administrative penalties for medical insurance fraud, and the investigation is meticulous and comprehensive. And the sufficient and conclusive requirements of the evidence are higher.

The second is that the hidden medical insurance fraud needs to pass more comprehensive inspections and audits to fully expose it. General intelligent monitoring and inspection are difficult to find. Take high -value consumables only as an example. First, it is necessary to obtain clear documents. When the medical expenses details are not indicated on the necessary information such as the brand, the medical institution is required to be further provided; the second is that when the medical institutions deny illegal and illegal acts, It is necessary to check the records of medical institutions and even inventory to find out the actual consumables; third, it may be necessary to investigate the staff, patients and their families of medical institutions to further lock the actual consumables; If necessary, it may also need to conduct further investigations based on the purchase records provided by the medical institution. Overall, case investigation and punishment takes time, laborious, and expensive.

As my country's medical insurance basically achieves full coverage, the number of pharmaceutical institutions has risen sharply, private pharmaceutical institutions have increased significantly. The number of institutional audit staff is generally insufficient, especially the phenomenon of institutions at the county level and below. Multi -level medical insurance regulatory departments also have problems with the professionalism of auditing teams. Some lack medical professional knowledge, some lack of discipline knowledge such as law, evidence, statistics, etc., and the supervision efficiency is not high. The direct consequence of this is that medical insurance supervision mainly relies on intelligent monitoring based on big data screening, and there is a large deficiencies in offline comprehensive audit and inspection and supervision. Taking the recent official launch of the 2022 National Medical Insurance Fund Flight Examination as an example, the Heilongjiang Group Flight Examination lasted about 10 days. It is intended to have hemodialysis therapy for the payment scope of the medical insurance fund, high -value medical consumables (orthopedics, Cardiology Department of Orthopedics, Cardiology ) Use for inspection and other conditions, and severely crack down on the behavior of deceiving medical insurance funds through fake medical documents and fictional pharmaceutical service projects. Obviously, the proportion of medical institutions inspected by the National Fair Inspection Team accounts for a very low proportion of the overall medical institution, which is inevitable that the human, material and financial resources of the National Fair Inspection Group must be determined. This is not only the national flight inspection team, but also the local offline inspection, this situation will definitely exist for a long time. The concealment of medical insurance fraud and the large law enforcement costs of such violations of laws and regulations determine the unable to conduct offline audit and inspection of the medical insurance payment situation of medical institutions. It is necessary to "take a different approach" and fully consider the management function of the medical insurance agreement, especially for the default of the medical insurance fund use -medical insurance fraud is also a breach of contract. Start curb.

Anti -fraud function of liability liability

The liquidated contract is part of the contract. The liability for the default damage set by the liquidated damage clause is one of the liability for the contract, especially one of the liability for breach of contract. Analysis of liability for liquidation damages must first be clarified to the nature of medical insurance agreements signed by the medical insurance agency and medical institutions.

The legal nature of the medical insurance agreement. Article 3 of the "Interim Measures for Medical Institutions' Medical Security Designation" (National Medical Security Agency Order No. 2) stipulates that the agency is responsible for determining the designated medical institution and signed a medical security service agreement with designated medical institutions (that is, the "Medical Insurance Agreement" ), Provide management services, carry out management, assessment, and assessment. But this method does not clear the legal nature of the medical insurance agreement. The "Supreme People's Court's Provisions on Several Issues of the CPPCO Council" (Fa Shi [2019] No. 17) stipulates that in order to achieve administrative management or public service goals, the administrative organs have a Agreement on the content of rights and obligations in administrative law belongs to the administrative agreement stipulated in Article 12 (2), paragraph 11 of the Administrative Procedure Law. Social insurance belongs to the category of administrative management in my country, and itself is also a public service project. The main entity of the organizer is an administrative subject in my country. Therefore, the medical insurance agreement should be an administrative agreement. First of all, it belongs to the contract and has a conformity, and it should follow the basic rules of the contract. Secondly, it belongs to administrative acts and has administrative nature and needs to comply with the basic requirements of administrative behavior.

Can a liquidated damage in the medical insurance agreement. Article 19, paragraph 2 of the "Supreme People's Court on Several Issues of the CPPCO Council", stipulates that if the defendant fails to perform the administrative agreement in accordance with the law and fails to perform the administrative agreement in accordance with the agreement, the plaintiff shall be compensated in accordance with the agreed liquidated contract or deposit clause, the people shall be compensated, the people shall be compensated, the people shall The court should support. The judicial interpretation does not stipulate that the administrative agreement may agree on the liability for a derived of liquidated damages. Article 14 and 38 of the "Interim Measures for the Management of Medical Institutions for Medical Institutions" should be used as principled regulations on the liquidated damages that the medical institution should bear. Given that the medical insurance agreement as an administrative agreement has contract attributes, and the liability and liability for liability for liability for liquidation and liability for liquidation, liability and liability for liability for liquidated damages should be allowed to set liability for liability for liability in the medical insurance agreement.

The nature of liability for liquidation and its purpose. According to the function of liability for liability and its purpose, it can be divided into compensation liquidated damages and punitive liquidated damages. The "Interim Measures for the Management of Medical Security for Medical Institutions" does not stipulate the nature of liquidated damages. Article 585, paragraph 1 of the Civil Code stipulates that the parties may agree that one party should pay a certain amount of liquidated damages to the other party according to the breach of contract, or it may agree on the calculation method of the loss of compensation caused by the breach of contract. This provision is a compensation liquidated damage, that is, the reservation for the damage compensation caused by the breach of contract is not punished. my country's "Civil Code" does not stipulate the penalty liquidated damages, but generally acknowledges punishment liquidated damages in judicial practice.

The punishment liquidated damage is the sanctions on the default of the debtor to urge the debtor to fulfill the obligations in strict accordance with the contract of the contract, so as to guarantee the realization of the legitimate interests of the creditors. The inheritance of penalties for punishment liquidated damages, that is, the inherent attributes of the liquidated damages should be punished according to the inherent attributes of the liquidated damages -the function of compensation liquidated damages can be achieved through the default damage compensation system, and it may not be realized through liability for liability. The liability for punishment liquidated damages is due to punitive consequences of the breach of contract, which urges the counterparty to strictly abide by and fulfill the contractual obligations of the contract, so it has anti -fraud function. Compared with administrative penalties, punitive penalties have considerable advantages: First, it is implemented based on the breach of contract of medical institutions. It does not need to determine the subjective breach of the medical institution. Essence Second, it can cover the investigation and processing costs of the agency. Under the current administrative management system, the cost of investigation and treatment of administrative penalties should be fiscal budget costs. Based on budget restrictions, administrative subjects may compress the investigation and disposal of cases in order to control the investigation and handle costs; Considering the cost of investigation and processing costs into punitive liquidated damages can be considered, which can alleviate the cost anxiety of administrative subjects investigation and disposal to a large extent. Third, the calculation and implementation of punitive liquidated damages and implementation are simple and easy to implement, which is in line with the principle of administrative efficiency. Fourth, punitive liquidated damages have significantly increased the cost of violations, violations, and breach of contracts of medical institutions, and can curb the scamming motivation of medical institutions. The setting of the liability for the liability of the medical insurance agreement and the performance

From the perspective of the provisions of the medical insurance agreements in various places, the liability clauses of the liability for liability are still lacking. Some are completely unswerving, and some only abstract the clause of liquidated damages without specific amounts, and some conditions are unreasonable. For example, a medical insurance agreement stipulates that the medical institution "without the training or lecture organ organized by the medical security department or the agency", if you refuse to make corrections, depending on the serious and risk of risk, you can pay 10% of the cost of last month. Pay liquidated damages; medical institutions "decompose hospitalization, hang bed hospitalization", "illegal diagnosis and treatment specifications, excessive diagnosis and treatment, excessive examination, decomposition prescription, over -drug prescription, repeated medicine or other unnecessary medical services" Tolls and decomposition project charges "," skewers, medical consumables, diagnosis and treatment projects and service facilities "," category of settlement of insured personnel settlement medical categories ", which does not cause the loss of medical security funds. Responsible departments (personnel) medical insurance services, suspended from January to June, and paid a liquidated damage at 10%of the cost of last month. Based on breach of contract, the liability for breach of contract is liability for breach of contract, rather than compulsory performance measures. It is not suitable to refuse to correct the breach of contract; in terms of medical insurance agreement, any violations, violations, or breach of the medical institution will cause medical insurance to produce medical insurance menstruation. If the loss of institutions and medical insurance administrative departments, if it occupies administrative resources, even from the perspective of compensation liquidated damages, it should still be held accountable for medical institutions' liability for liquidated damages.

In order to better curb the illegal, violations, and default behaviors of medical institutions, and better curb medical insurance fraud in medical institutions, it should further improve the liability for liability in the medical insurance agreement:

First, it shall make as much as possible to the liquidated damages and clarify the specific liability for liquidated damages. The requirements for breach of contracts at all do not agree with the requirements of the "Interim Measures for Medical Institutions Medical Insurance Purpose of Medical Institutions".

The second is to clearly agree on the applicable conditions for liquidated damages. For medical institutions involving the payment of medical insurance funds, they shall apply a liquidated damage, instead of involving the fund payment. Applicable liquidated damages.

The third is to clarify the amount of liquidated damages. The amount of liquidated damages should not be too low, otherwise it will not only play a role in anti -fraud, but may indulge fraud. The amount of liquidated damages should be determined by a certain percentage of the total annual or this year's total prepaid. For the first time as a fixed -point medical institution, the specific amount of specific amounts such as 1 million yuan — refer to the scale of the medical institution and the possible medical insurance payment amount. It should be noted that the agreed amount of liquidated damages does not equal the amount of liquidated damages for the final execution. While the agreed high liquidated damages to curb the motivation of the medical institution to fraud, if the employer is illegal, illegal, and default, the violations are mild, the invasion of the fund invades the fund The amount is low, and the two parties can negotiate the amount of liquidated damages that the medical institution will bear in the end, thereby reflecting the characteristics of the flexible administrative characteristics of the administrative agreement.

It can be based on the different nature of the medical institutions, violations, violations, default behaviors and behavior repetition rates, and behavior time span.

In view of the fact that the medical institutions were discovered and investigated and punished are only small parts, more violations, violations, and breach of contract were not found in reality. The combination of responsibilities such as medical insurance funds.

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