Credit system could help reduce medical scams

China plans to develop a points-based credit system for healthcare professionals who are certified to process medical insurance funds to curb the misuse of funds and strengthen punishment for violators, according to a guideline released recently.

Similar to the nation's point system for driver's licenses, the new system will target relevant staff members at insurance-designated medical institutions as well as owners of pharmacies, according to the guideline jointly released by the National Healthcare Security Administration, the National Health Commission and the National Medical Products Administration on Sept 27.

Workers who are found to have engaged in dishonest or illegal behavior will have points assigned to them in the system deducted. They can lose one to three points for minor offenses, while the most severe violations will result in a loss of 10 to 12 points.

Those who lose nine to 11 points in a year will see their insurance payment certifications suspended for one to six months, which also means that patients who use healthcare services and medications prescribed by them — except for first aid and emergency care services — will not be reimbursed for the amount they spent on these services.

An accumulation of 12 deducted points will lead to revocation of their eligibility to work as certified insurance agents. Also, they will not be allowed to apply for the qualification again for one to three consecutive years, depending on specific conditions.

Gu Rong, head of the National Healthcare Security Administration's fund supervision department, said that information on certification suspensions or revocations will be shared nationwide and reported to health authorities and drug regulators to ensure joint supervision.

"In the future, we will also consider establishing individual insurance credibility files for relevant personnel to track points and monitor their compliance with insurance rules and regulations throughout their career," he said.

Despite the nation's intensifying oversight over healthcare insurance funds in recent years, irregular and illegal use of insurance funds remains rampant.

In a recent case that drew widespread public attention, medical workers at a hospital in Wuxi, Jiangsu province, are suspected of fabricating medical records to obtain insurance payments.

"An outstanding challenge is that although we have cracked down on a number of offenses, we can only implement supervision on and hand penalties to specific institutions rather than individuals," Gu said. "So some violators simply change their identities and resume their old occupations elsewhere."

Gu said that extending the regulatory scope from designated medical institutions to all healthcare personnel and pharmacy managers is expected to enhance oversight and increase deterrence.

He added that the guideline highlights the significance of gradual and steady implementation to avoid a one-size-fits-all approach. Local authorities are asked to put all relevant personnel under supervision within three years, and they are allowed to tailor specifics of the guidelines based on local circumstances and roll out pilot programs first.

The administration said that this year, it has carried out unannounced inspections at 500 insurance-designated medical institutions across the nation.

These inspections have led to the discovery of 2.21 billion yuan ($344 million) in misused insurance funds. From January to August, healthcare fund regulators nationwide regained 13.66 billion yuan of ill-gotten insurance funds.

Yan Qinghui, deputy director of the administration, stressed that supervising insurance funds remains complicated and requires long-term efforts to root out existing problems while curbing potential offenses.