Common health insurance fraud tricks

The deficit of the health insurance fund is very serious. One of the reasons for the deficit of the health insurance fund is that health insurance fraud still occurs frequently and widely. Taking advantage of loopholes, some subjects have tried to profit from health insurance, embezzling a large amount of money and it has occurred in almost all types and insurance activities, from health insurance participants to medical facilities.

In 2017, the Health Insurance Fund collected 80,000 billion VND, but spent 85,000 billion VND... There were 38 provinces and cities with an increase in medical examination and treatment costs of over 40% compared to the same period in 2016, some provinces increased by over 70% such as: Kon Tum, Quang Tri, Binh Phuoc, Khanh Hoa. There were 15 provinces with an increase of over 20% in the number of medical examinations and treatments such as Binh Phuoc 42.4%, Hau Giang 33%, Binh Duong 31.4%...

Operating since June 25, 2016, the Health Insurance Assessment Information System, through statistics, shows that the frequency of medical examinations using Health Insurance cards of many patients shows signs of health insurance fraud. For example, statistics in the first 5 months of 2017 in 46 provinces and cities recorded 2,769 people having 50 or more medical examinations. Most of the cases of examinations at 4 or more medical facilities have duplicate prescriptions, drug abuse, and rehabilitation procedures.

1580 people were found to have medical examinations 8 times/month at many medical facilities... Some people had 132 medical examinations in 8 months... Some people had 70 medical examinations. There were many cases of patients being treated at 2 hospitals at the same time, before being discharged from one hospital, they were admitted to another. Many cases of very mild illnesses such as sore throat, acne, rash, periodontitis were also prescribed to be hospitalized for 3-5 days...

In addition, there is the situation of borrowing health insurance cards to see a doctor. Not only patients but also medical staff take advantage of health insurance by taking the card data of people who have moved to another place to create records, embezzling tens of millions of dong.

Mr. Phan Van Toan, Deputy Director of the Department of Health Insurance, Ministry of Health said: "The system automatically detected and rejected over 10% of payment requests with an amount of nearly 3,000 billion VND due to incorrect information about health insurance."

The representative of Vietnam Social Security said that the reason for the increase in health insurance examination and treatment costs, in addition to the increase in medical service prices, is that many medical facilities do not comply with the prescribed norms, there are many shortcomings in the statistics of technical service payments, duplicated technical service orders, abuse of test orders and increased inpatient and outpatient treatment... In addition, due to the high cost of hospital beds, many medical facilities profit by prolonging the inpatient stay of patients.

Comparison by Master, Doctor Le Van Phuc - Deputy Head of the Department in charge of Health Insurance Policy - Vietnam Social Insurance shows: "In 2016, when the full price of medical services had not been applied in localities, the Health Insurance Fund had a deficit of about 6 trillion VND and by 2017, when all localities had applied this price of medical services, in 2017 the Health Insurance Fund continued to have a higher deficit than in 2016".

On the side of medical staff, they profited by retrieving card data of people who had moved elsewhere to create fake records, embezzling tens of millions of dong. In Vinh Long, a doctor created 272 fake medical examinations and treatments to request payment of more than 49 million dong….

Or some medical facilities have separated services and surgeries to pay additional costs. Especially, the appointment of patients to stay overtime has caused the cost of health insurance to increase significantly. For example, Phaco surgery requires a 2-day stay, but some hospitals allow 7-8 days.

Prescribing unnecessary tests and diagnostic imaging... are errors that the health insurance appraisal information system detects and refuses to pay. In particular, the situation of patients going to the clinic many times a day, a month, a year, profiting tens of billions of VND from the health insurance fund has also been detected by the system.

From January 1, 2018, the 2015 Penal Code, revised in 2017, will officially take effect, including provisions on 3 crimes related to social insurance and health insurance. The law comes into effect with the expectation that it will become a powerful "tool" to strengthen measures and sanctions to help the social insurance sector effectively enforce the law, ensuring the rights of employees and health insurance participants.

Mr. Pham Luong Son - Deputy General Director of Vietnam Social Security said that this is also one of the tools and support for both the police force and local public security as well as the inspection and examination force of the Social Security sector to better fulfill the set tasks and goals.

Regarding the health sector, Minister Nguyen Thi Kim Tien said that in the coming time, inspection and supervision will be strengthened, then inspection and strict handling of violations of technical abuse, health insurance profiteering, and at the same time, violations will be handled if the Social Insurance agency refuses to make reasonable payments to patients and hospitals.

Vietnam Social Security is also trying to develop a project to change the appraisal work. In 2018, it strives to have 100% of records electronically appraised for monitoring, creating favorable and transparent conditions for payment of medical examination and treatment.

“Through electronic appraisal of the Social Insurance Agency in the first 4 months of 2017, the electronic appraisal system automatically rejected 3,000 billion VND out of 17,000 billion VND that medical facilities requested to pay. This is an effective tool in preventing abuse and profiteering of health insurance, it ensures publicity, transparency and timely detection of signs and abuse of health insurance funds” - Mr. Phan Dang Toan - Deputy Director of Health Insurance Department, Ministry of Health added./.