Tongji Hospital's Massive Insurance Fraud Case: The Challenges of Medical Insurance Supervision for Top-tier Hospitals Industry News at 8 Health News 2022.04.29 10:34 Insurance fraud, Tongji Hospital, involving nearly 100 million yuan... This is the first time that the National Medical Insurance Bureau has separately announced the results of a flight inspection of a hospital, causing a sensation in the industry - top-tier hospital, maximum penalty, large amount, and serious nature. According to the announcement of the National Medical Insurance Bureau, Tongji Hospital embezzled more than 23.34 million yuan from the medical insurance fund from 2017 to 2020, through "substitution and false recording of high-value orthopedic medical consumables". In addition, in 2021, there was suspected improper use of medical insurance funds amounting to more than 91.07 million yuan, which is still under verification and processing. The main character of the case is Tongji Hospital affiliated with Tongji Medical College of Huazhong University of Science and Technology, which was established in 1900 and is one of the top-tier hospitals in China. In the 2020 Comprehensive Ranking of Chinese Hospitals released by the Institute of Hospital Management of Fudan University, it ranked sixth nationwide. The announcement shows that the hospital conducted a self-examination and voluntarily returned 19.15 million yuan, and after the inspection, it was found that the embezzled amount was 4.18 million yuan. The former was fined twice the amount - nearly 40 million yuan, and the latter was fined five times the amount - over 20 million yuan. In addition, the hospital was ordered to suspend orthopedics for 8 months involving the use of medical insurance funds for pharmaceutical services. This touches on the maximum amount of fines for insurance fraud stipulated in the "Regulations on the Supervision and Administration of the Use of Medical Security Funds" promulgated in 2021: fines of two to five times the amount embezzled, and ordering designated medical institutions to suspend pharmaceutical services involving the use of medical security funds for six months to one year. An informed source told 8 Health News that the inspection process of this case has been full of twists and turns, with disputes over the intensity of the investigation and how to expose it. The first to expose the case was the Wuhan Medical Insurance Bureau. On April 18, the official website of the Wuhan Medical Insurance Bureau announced the basic information of the case, including the departments involved, the time span, the amount of violations, and the punishment measures. The subject of the inspection was the "Wuhan Medical Insurance Bureau", and the nature was "improper use of medical insurance funds". On April 20, the National Medical Insurance Bureau once again announced relevant information about the case, with more detailed content, directly classifying the case as "embezzlement of medical insurance funds", and the subject of the inspection was the "National Medical Insurance Bureau, in conjunction with the National Health Commission and the State Administration for Market Regulation", "guiding the Hubei Provincial Medical Insurance Bureau and the Wuhan Medical Insurance Bureau to verify and handle relevant issues". And for the first time, it revealed that there are still nearly four times the confirmed amount of funds to be investigated and dealt with. A doctor familiar with the medical system in Wuhan told 8 Health News that this round of inspections had started in early February, with dozens of members in the national inspection team, some of whom were seconded from other medical insurance bureaus. "Some places, when they discover problems, are afraid to dig deep and investigate rigorously. They dare not deal with them severely and quickly. Even the problems found by the national inspection team, instead of pursuing them further, they help cover them up and intervene, and dare not expose the cases for fear of tarnishing the local party committee and government." On April 22, the China Medical Insurance, a journal under the supervision of the National Medical Insurance Bureau, published a social commentary titled "Three Insights from the 'Tongji Hospital Incident'". "It not only distorts the role positioning of fund regulators, failing to fulfill their responsibilities, but more importantly, it greatly undermines the power of fund regulation." The commentary in China Medical Insurance went on to say, "It once again illustrates the long-term, arduous, and complex nature of the work of combating fraud and safeguarding fund security." Wuhan Tongji Hospital is affiliated with the National Health Commission and is one of dozens of "national-level" hospitals in China. The pressure of the investigation can be imagined. Moreover, it is difficult to detect the substitution of consumables implanted in the body. Coupled with the high trust in authoritative hospitals and doctors, whether the consumables are genuine or not is unlikely to arouse suspicion among patients. However, this time, the key to the case being investigated and dealt with was the provision of solid evidence and reports by the manufacturers of consumables in the chain of interests. "Substituting consumables, passing off inferior products, it's a simple and crude method." commented an industry insider, "It's intentional and typical insurance fraud." Zhang Qiang, the founder of Zhang Qiang Medical Group, also believes that the method of insurance fraud by substituting consumables is more difficult to investigate, and hopes that this case will be treated as an individual case. If similar insurance fraud patterns are replicated in more hospitals, the cost of insurance investigation will be significant. "Tongji is our benchmark, and this investigation has given a warning to all hospitals in Wuhan." said the aforementioned doctor in the Wuhan medical system to 8 Health News. "I didn't expect it to be exposed like this, we are all shocked." said an informed source frankly. Currently, the inspection and punishment information regarding specific personnel has not been publicly announced. According to Upstream News, during the investigation, the person in charge of the orthopedics department of the hospital has been taken away by judicial authorities. In addition, multiple sources have informed 8 Health News that a retired vice president of Tongji Hospital has been taken away several days ago. It is reported that the whistleblower has reported to the Central Commission for Discipline Inspection, and according to convention, the public security department and the Central Commission for Discipline Inspection will also issue relevant notifications. Cat and Mouse Game: Administrative Protection and Medical Barriers The peak of the infection has passed, but there has been a large-scale occurrence of critical illness and death. Professionals believe that this situation does not deter fraud and insurance fraud. This movement governance, which has been launching heavy blows since the establishment of the National Medical Insurance Bureau in 2018, has achieved results in 2021 by recovering 23.4 billion yuan of medical insurance funds and investigating more than half of the medical institutions for irregularities. Four years ago, at a crossroads, universal medical insurance faced fragmented management institutions, high medical expenses, and the risk of fund depletion. In 2018, the employee medical insurance in 106 pooling areas and the resident medical insurance in 183 pooling areas had insufficient income to cover expenses, with deficits of 8.34 billion yuan and 15.4 billion yuan, respectively - equivalent to the total amount of recovered medical insurance funds in 2021. Therefore, medical insurance cost control, with fund supervision, volume-based procurement, medical insurance catalog negotiations, and payment method reforms as the main focus, became imperative, and the fragmented management authority was consolidated into the large medical security bureau, in order to form strong constraints and bargaining power. Supply and demand determine bargaining. Although the medical insurance bureau is a super payer with trillions of funds, in China's medical service system, public hospitals, and even top-tier hospitals, still exist as a dominant supply side monopoly. They often monopolize regional high-quality medical resources and patient groups. Once the medical insurance settlement is stopped, it can easily cause local livelihood problems. Coupled with the power of the top-tier hospitals to attract patients from surrounding areas, medical treatment in other regions, separate settlement by provinces, has weakened the dependence of hospitals on various medical insurance bureaus, and power has become severely imbalanced. In fact, Tongji Hospital joined the Wuhan Medical Insurance very late. According to reports from Changjiang Business Daily and Changjiang Daily, in 2013, Tongji Hospital announced that the Cardiovascular Surgery Department became the first department of the hospital to be designated by the Wuhan Medical Insurance, and the entire Tongji Hospital joined the Wuhan Medical Insurance in 2021. In addition, the administrative protection capability possessed by top-tier hospitals also makes regulators hesitant. Lou Yu, a professor at the School of Civil and Commercial Economic Law of China University of Political Science and Law, introduced that administrative protection capability refers to public hospitals pressuring local health departments and government departments to put pressure on the medical insurance department, using the excuse that investigating fraud and insurance fraud will affect medical behavior and damage the hospital's image, thus obstructing inspections. "The higher authorities can crush the lower ones." In the daily inspections of the medical insurance department, the head of the supervision department encounters the director of a public hospital at the department level, and the resistance can be imagined. Not to mention the Wuhan Tongji Hospital in the vortex, with its dual identity as a provincial and central hospital. In a flight inspection by the medical insurance department in 2019, a top-tier hospital in a central province and city directly shut down the computer and refused the inspection, but in the end, it was found that the medical insurance funds were used improperly and fined over 100 million yuan. At the same time, the newly established medical insurance departments in various regions are not only supervising public hospitals but also various parties in the chaotic medical and pharmaceutical fields, and manpower is often the first constraint. Taking Zigong City in the western region as an example, there are 158 employees in the medical insurance agency and administrative agency, corresponding to over 1,300 designated medical institutions and 2.7879 million insured persons. On average, one staff member has to serve over 17,000 insured persons, making it easy to have blind spots in supervision. An auditor from a provincial medical insurance bureau in the eastern region introduced that the department has been established for three years, and the manpower is relatively weak, with a lack of clinically specialized personnel. He summarized the regularity of annual inspections: two weeks for top-tier hospitals, one week for secondary hospitals, and only one or two days for community health centers. "Due to limited manpower, it is impossible to be stationed at top-tier hospitals every day, and if it is too long, it will interfere with medical behavior." The medical gap is another strong barrier for public hospitals. Although the existing inspection teams have tried their best to have specialized and diverse personnel, several interviewees still expressed that at the current stage, there are laws to rely on for compliance inspections, but when it comes to problems discovered based on medical experience, there is a lack of clear legal basis, and hospitals may refuse to acknowledge them. A commercial insurance practitioner sees this as the difference between clinical medicine and insurance medicine. The former focuses on the best efficacy, while the latter focuses more on the best cost-effectiveness. Under the guise of providing the best efficacy, some people unknowingly violate regulations, while others repeatedly test the boundaries in the gray area, looking for management loopholes. With the deepening of the campaign to combat fraud and insurance fraud, these methods are constantly changing. For the two parties providing services to patients - medical insurance and hospitals, through different paths, they become a "cat and mouse game". How to regulate top-tier hospitals? Faced with powerful top-tier hospitals, flight inspections initiated by the National Medical Insurance Bureau are like a "magic sword". So-called flight inspections are mainly targeted at major hospitals and designated medical institutions across the country. They enter the site without prior notice. This long-lasting "squeezing" movement, which lasts for days, has expanded from "soft targets" such as private hospitals, high-cost populations, and patients seeking medical treatment in other regions to "hard nuts" - large local public hospitals. The first to be hit was the Second Xiangya Hospital. In December 2019, the Hunan Provincial Medical Security Bureau disclosed that the hospital had serious violations of the use of medical insurance funds, such as false recording of surgical suture and other consumable costs, excessive examinations, and excessive medical treatment. The illegally used medical insurance funds were recovered, and a total of 33.5926 million yuan in fines were imposed. In the same year, a set of flight inspection data from the National Medical Insurance Bureau showed that in 39 inspections, lasting 33 days, insurance fraud amounting to 260 million yuan was confirmed, with an average of over 6 million yuan per inspection. Its deterrent power should not be underestimated. Following closely behind was the intervention of the Health Commission. After conducting supervisory inspections of 27 of them, the Health Commission stated that although the 27 hospitals had irregularities in the use of medical insurance funds, there was no serious violation of "insurance fraud". "Improper use of medical insurance funds" or "insurance fraud"? Many industry insiders have stated that there is a lot of flexibility in the interpretation and selective enforcement of these terms. The "Regulations on the Supervision and Administration of the Use of Medical Security Funds" officially implemented in May 2021 is the only administrative regulation in the field of fund supervision. Articles 38 and 40 respectively stipulate the handling of these two types of behaviors, with fines of one to two times the amount of losses for the former, and fines of two to five times the amount for the latter. The deterrent power and severity are self-evident. No one can accurately interpret it based on the amount or fraudulent means. A medical insurance expert pointed out that whether there is intent is one of the influencing factors, and the aforementioned commercial insurance practitioner also stated that in "typical" cases, the maximum penalty is generally imposed. Tongji Hospital is undoubtedly the selected "typical" case. Other cases involving large amounts have not been disclosed in detail. In a policy briefing in July 2021, Duan Zhengming, Deputy Director of the Fund Supervision Department of the National Medical Insurance Bureau, revealed that one hospital had returned more than 900 million yuan of irregular medical insurance funds. Large public hospitals have larger amounts of insurance fraud and more concealed methods, almost becoming a common secret in the industry. Compared with fines, Lou Yu pointed out that cooperation between law enforcement agencies is an effective means of regulating public hospitals, and the involvement of public security agencies can form effective deterrence. Behind the "big but not falling" is the external public welfare attribute associated with public hospitals. Many experts believe that the handling of this case has achieved a balance between protecting people's livelihoods and deterrent effects. Zhang Qing, a professor at the Law School of China University of Political Science and Law, pointed out that for some departments in top-tier hospitals that require high technical standards, if their services cannot be replaced locally, considering the clinical treatment needs of the majority of insured persons, the two penalty measures of terminating or suspending agreements should be used with caution. The aforementioned medical insurance expert believes that closing departments is already a second-best choice, and in the medical circle of top-tier hospitals in Wuhan, suspending Tongji Hospital's orthopedic medical insurance services is more of a warning. However, any changes made are not cliff-like. The Fund Supervision Regulations, the "Draft Medical Insurance Law", and the notice on the connection between law enforcement and execution have been successively issued, and the medical insurance department has more tools in hand. Some grassroots practitioners feel that their work has become much easier, "compared to the rough framework of the original Social Insurance Law, now we can follow the regulations more closely." This year marks the fifth year of the "campaign to combat fraud and insurance fraud". The movement governance approach will eventually come to an end, and the process of leveraging medical reform with medical insurance is particularly difficult. But regardless of who is ultimately targeted, what we always expect is a society that values fairness and people's livelihoods. As individuals in this society, can we avoid being affected by the fighting of these immortals and causing harm to ourselves?

Tongji Hospital's Massive Insurance Fraud Case: The Challenges of Medical Insurance Supervision for Top-tier Hospitals

Industry News at 8 Health News 2022.04.29 10:34

Insurance fraud, Tongji Hospital, involving nearly 100 million yuan...

This is the first time that the National Medical Insurance Bureau has separately announced the results of a flight inspection of a hospital, causing a sensation in the industry - top-tier hospital, maximum penalty, large amount, and serious nature.

According to the announcement of the National Medical Insurance Bureau, Tongji Hospital embezzled more than 23.34 million yuan from the medical insurance fund from 2017 to 2020, through "substitution and false recording of high-value orthopedic medical consumables".

In addition, in 2021, there was suspected improper use of medical insurance funds amounting to more than 91.07 million yuan, which is still under verification and processing.

The main character of the case is Tongji Hospital affiliated with Tongji Medical College of Huazhong University of Science and Technology, which was established in 1900 and is one of the top-tier hospitals in China. In the 2020 Comprehensive Ranking of Chinese Hospitals released by the Institute of Hospital Management of Fudan University, it ranked sixth nationwide.

The announcement shows that the hospital conducted a self-examination and voluntarily returned 19.15 million yuan, and after the inspection, it was found that the embezzled amount was 4.18 million yuan. The former was fined twice the amount - nearly 40 million yuan, and the latter was fined five times the amount - over 20 million yuan.

In addition, the hospital was ordered to suspend orthopedics for 8 months involving the use of medical insurance funds for pharmaceutical services.

This touches on the maximum amount of fines for insurance fraud stipulated in the "Regulations on the Supervision and Administration of the Use of Medical Security Funds" promulgated in 2021: fines of two to five times the amount embezzled, and ordering designated medical institutions to suspend pharmaceutical services involving the use of medical security funds for six months to one year.

An informed source told 8 Health News that the inspection process of this case has been full of twists and turns, with disputes over the intensity of the investigation and how to expose it.

The first to expose the case was the Wuhan Medical Insurance Bureau. On April 18, the official website of the Wuhan Medical Insurance Bureau announced the basic information of the case, including the departments involved, the time span, the amount of violations, and the punishment measures. The subject of the inspection was the "Wuhan Medical Insurance Bureau", and the nature was "improper use of medical insurance funds".

On April 20, the National Medical Insurance Bureau once again announced relevant information about the case, with more detailed content, directly classifying the case as "embezzlement of medical insurance funds", and the subject of the inspection was the "National Medical Insurance Bureau, in conjunction with the National Health Commission and the State Administration for Market Regulation", "guiding the Hubei Provincial Medical Insurance Bureau and the Wuhan Medical Insurance Bureau to verify and handle relevant issues". And for the first time, it revealed that there are still nearly four times the confirmed amount of funds to be investigated and dealt with.

A doctor familiar with the medical system in Wuhan told 8 Health News that this round of inspections had started in early February, with dozens of members in the national inspection team, some of whom were seconded from other medical insurance bureaus.

"Some places, when they discover problems, are afraid to dig deep and investigate rigorously. They dare not deal with them severely and quickly. Even the problems found by the national inspection team, instead of pursuing them further, they help cover them up and intervene, and dare not expose the cases for fear of tarnishing the local party committee and government." On April 22, the China Medical Insurance, a journal under the supervision of the National Medical Insurance Bureau, published a social commentary titled "Three Insights from the 'Tongji Hospital Incident'".

"It not only distorts the role positioning of fund regulators, failing to fulfill their responsibilities, but more importantly, it greatly undermines the power of fund regulation." The commentary in China Medical Insurance went on to say, "It once again illustrates the long-term, arduous, and complex nature of the work of combating fraud and safeguarding fund security."

Wuhan Tongji Hospital is affiliated with the National Health Commission and is one of dozens of "national-level" hospitals in China. The pressure of the investigation can be imagined.

Moreover, it is difficult to detect the substitution of consumables implanted in the body. Coupled with the high trust in authoritative hospitals and doctors, whether the consumables are genuine or not is unlikely to arouse suspicion among patients.

However, this time, the key to the case being investigated and dealt with was the provision of solid evidence and reports by the manufacturers of consumables in the chain of interests.

"Substituting consumables, passing off inferior products, it's a simple and crude method." commented an industry insider, "It's intentional and typical insurance fraud." Zhang Qiang, the founder of Zhang Qiang Medical Group, also believes that the method of insurance fraud by substituting consumables is more difficult to investigate, and hopes that this case will be treated as an individual case. If similar insurance fraud patterns are replicated in more hospitals, the cost of insurance investigation will be significant.

"Tongji is our benchmark, and this investigation has given a warning to all hospitals in Wuhan." said the aforementioned doctor in the Wuhan medical system to 8 Health News.

"I didn't expect it to be exposed like this, we are all shocked." said an informed source frankly.

Currently, the inspection and punishment information regarding specific personnel has not been publicly announced. According to Upstream News, during the investigation, the person in charge of the orthopedics department of the hospital has been taken away by judicial authorities. In addition, multiple sources have informed 8 Health News that a retired vice president of Tongji Hospital has been taken away several days ago.

It is reported that the whistleblower has reported to the Central Commission for Discipline Inspection, and according to convention, the public security department and the Central Commission for Discipline Inspection will also issue relevant notifications.

Cat and Mouse Game: Administrative Protection and Medical Barriers

The peak of the infection has passed, but there has been a large-scale occurrence of critical illness and death. Professionals believe that this situation does not deter fraud and insurance fraud. This movement governance, which has been launching heavy blows since the establishment of the National Medical Insurance Bureau in 2018, has achieved results in 2021 by recovering 23.4 billion yuan of medical insurance funds and investigating more than half of the medical institutions for irregularities.

Four years ago, at a crossroads, universal medical insurance faced fragmented management institutions, high medical expenses, and the risk of fund depletion. In 2018, the employee medical insurance in 106 pooling areas and the resident medical insurance in 183 pooling areas had insufficient income to cover expenses, with deficits of 8.34 billion yuan and 15.4 billion yuan, respectively - equivalent to the total amount of recovered medical insurance funds in 2021.

Therefore, medical insurance cost control, with fund supervision, volume-based procurement, medical insurance catalog negotiations, and payment method reforms as the main focus, became imperative, and the fragmented management authority was consolidated into the large medical security bureau, in order to form strong constraints and bargaining power.

Supply and demand determine bargaining. Although the medical insurance bureau is a super payer with trillions of funds, in China's medical service system, public hospitals, and even top-tier hospitals, still exist as a dominant supply side monopoly. They often monopolize regional high-quality medical resources and patient groups. Once the medical insurance settlement is stopped, it can easily cause local livelihood problems.

Coupled with the power of the top-tier hospitals to attract patients from surrounding areas, medical treatment in other regions, separate settlement by provinces, has weakened the dependence of hospitals on various medical insurance bureaus, and power has become severely imbalanced.

In fact, Tongji Hospital joined the Wuhan Medical Insurance very late. According to reports from Changjiang Business Daily and Changjiang Daily, in 2013, Tongji Hospital announced that the Cardiovascular Surgery Department became the first department of the hospital to be designated by the Wuhan Medical Insurance, and the entire Tongji Hospital joined the Wuhan Medical Insurance in 2021.

In addition, the administrative protection capability possessed by top-tier hospitals also makes regulators hesitant. Lou Yu, a professor at the School of Civil and Commercial Economic Law of China University of Political Science and Law, introduced that administrative protection capability refers to public hospitals pressuring local health departments and government departments to put pressure on the medical insurance department, using the excuse that investigating fraud and insurance fraud will affect medical behavior and damage the hospital's image, thus obstructing inspections.

"The higher authorities can crush the lower ones." In the daily inspections of the medical insurance department, the head of the supervision department encounters the director of a public hospital at the department level, and the resistance can be imagined. Not to mention the Wuhan Tongji Hospital in the vortex, with its dual identity as a provincial and central hospital.

In a flight inspection by the medical insurance department in 2019, a top-tier hospital in a central province and city directly shut down the computer and refused the inspection, but in the end, it was found that the medical insurance funds were used improperly and fined over 100 million yuan.

At the same time, the newly established medical insurance departments in various regions are not only supervising public hospitals but also various parties in the chaotic medical and pharmaceutical fields, and manpower is often the first constraint.

Taking Zigong City in the western region as an example, there are 158 employees in the medical insurance agency and administrative agency, corresponding to over 1,300 designated medical institutions and 2.7879 million insured persons. On average, one staff member has to serve over 17,000 insured persons, making it easy to have blind spots in supervision.

An auditor from a provincial medical insurance bureau in the eastern region introduced that the department has been established for three years, and the manpower is relatively weak, with a lack of clinically specialized personnel. He summarized the regularity of annual inspections: two weeks for top-tier hospitals, one week for secondary hospitals, and only one or two days for community health centers. "Due to limited manpower, it is impossible to be stationed at top-tier hospitals every day, and if it is too long, it will interfere with medical behavior."

The medical gap is another strong barrier for public hospitals.

Although the existing inspection teams have tried their best to have specialized and diverse personnel, several interviewees still expressed that at the current stage, there are laws to rely on for compliance inspections, but when it comes to problems discovered based on medical experience, there is a lack of clear legal basis, and hospitals may refuse to acknowledge them.

A commercial insurance practitioner sees this as the difference between clinical medicine and insurance medicine. The former focuses on the best efficacy, while the latter focuses more on the best cost-effectiveness.

Under the guise of providing the best efficacy, some people unknowingly violate regulations, while others repeatedly test the boundaries in the gray area, looking for management loopholes. With the deepening of the campaign to combat fraud and insurance fraud, these methods are constantly changing.

For the two parties providing services to patients - medical insurance and hospitals, through different paths, they become a "cat and mouse game".

How to regulate top-tier hospitals?

Faced with powerful top-tier hospitals, flight inspections initiated by the National Medical Insurance Bureau are like a "magic sword".

So-called flight inspections are mainly targeted at major hospitals and designated medical institutions across the country. They enter the site without prior notice. This long-lasting "squeezing" movement, which lasts for days, has expanded from "soft targets" such as private hospitals, high-cost populations, and patients seeking medical treatment in other regions to "hard nuts" - large local public hospitals.

The first to be hit was the Second Xiangya Hospital. In December 2019, the Hunan Provincial Medical Security Bureau disclosed that the hospital had serious violations of the use of medical insurance funds, such as false recording of surgical suture and other consumable costs, excessive examinations, and excessive medical treatment. The illegally used medical insurance funds were recovered, and a total of 33.5926 million yuan in fines were imposed.

In the same year, a set of flight inspection data from the National Medical Insurance Bureau showed that in 39 inspections, lasting 33 days, insurance fraud amounting to 260 million yuan was confirmed, with an average of over 6 million yuan per inspection. Its deterrent power should not be underestimated. Following closely behind was the intervention of the Health Commission. After conducting supervisory inspections of 27 of them, the Health Commission stated that although the 27 hospitals had irregularities in the use of medical insurance funds, there was no serious violation of "insurance fraud".

"Improper use of medical insurance funds" or "insurance fraud"? Many industry insiders have stated that there is a lot of flexibility in the interpretation and selective enforcement of these terms.

The "Regulations on the Supervision and Administration of the Use of Medical Security Funds" officially implemented in May 2021 is the only administrative regulation in the field of fund supervision. Articles 38 and 40 respectively stipulate the handling of these two types of behaviors, with fines of one to two times the amount of losses for the former, and fines of two to five times the amount for the latter. The deterrent power and severity are self-evident.

No one can accurately interpret it based on the amount or fraudulent means. A medical insurance expert pointed out that whether there is intent is one of the influencing factors, and the aforementioned commercial insurance practitioner also stated that in "typical" cases, the maximum penalty is generally imposed. Tongji Hospital is undoubtedly the selected "typical" case.

Other cases involving large amounts have not been disclosed in detail. In a policy briefing in July 2021, Duan Zhengming, Deputy Director of the Fund Supervision Department of the National Medical Insurance Bureau, revealed that one hospital had returned more than 900 million yuan of irregular medical insurance funds.

Large public hospitals have larger amounts of insurance fraud and more concealed methods, almost becoming a common secret in the industry.

Compared with fines, Lou Yu pointed out that cooperation between law enforcement agencies is an effective means of regulating public hospitals, and the involvement of public security agencies can form effective deterrence.

Behind the "big but not falling" is the external public welfare attribute associated with public hospitals. Many experts believe that the handling of this case has achieved a balance between protecting people's livelihoods and deterrent effects.

Zhang Qing, a professor at the Law School of China University of Political Science and Law, pointed out that for some departments in top-tier hospitals that require high technical standards, if their services cannot be replaced locally, considering the clinical treatment needs of the majority of insured persons, the two penalty measures of terminating or suspending agreements should be used with caution.

The aforementioned medical insurance expert believes that closing departments is already a second-best choice, and in the medical circle of top-tier hospitals in Wuhan, suspending Tongji Hospital's orthopedic medical insurance services is more of a warning.

However, any changes made are not cliff-like. The Fund Supervision Regulations, the "Draft Medical Insurance Law", and the notice on the connection between law enforcement and execution have been successively issued, and the medical insurance department has more tools in hand. Some grassroots practitioners feel that their work has become much easier, "compared to the rough framework of the original Social Insurance Law, now we can follow the regulations more closely."

This year marks the fifth year of the "campaign to combat fraud and insurance fraud". The movement governance approach will eventually come to an end, and the process of leveraging medical reform with medical insurance is particularly difficult.

But regardless of who is ultimately targeted, what we always expect is a society that values fairness and people's livelihoods. As individuals in this society, can we avoid being affected by the fighting of these immortals and causing harm to ourselves?