In 2016, China began to establish a long-term care insurance system, and there are currently 49 national-level pilot projects across the country, and some regions have also begun to explore on their own. According to the 2022 National Statistical Communiqué on the Development of Medical Security, in 2022, a total of 16,990 people participated in long-term care insurance in 49 pilot cities20,000 people, 120 people enjoy treatment80,000 people. There are 7,679 designated service institutions for long-term care insurance, and 33 nursing service personnel10,000 people.
However, at the same time as the development of long-term care insurance, many people are eyeing long-term care, and stretching out the money for the life care of the disabled
There are insured people who obtain qualifications by disguising themselves:
In 2020, the Urban Operation Management Center of Yangpu District, Shanghai, monitored an elderly person with a level 6 severe disability "walking like flying" on the equipment in the gym through the "Supervision Scenario of the Whole Process of Long-term Care Insurance Assessment Service". At the time of the assessment, the old man was not only bedridden at home, but also placed a spittoon jar next to the bed, and implied to the people who came to the assessment that he had problems eating, drinking, and lazing, and could not get out of bed, so as to obtain long-term care qualifications.
There are caregivers who collude with the families of the insured to defraud the insurance
From May 2020 to November 2021, Xu Moumou, a caregiver at a nursing station, colluded with the family members of several elderly people in the nursing station, Zhou Moumou and Chen, to provide fictitious "long-term care insurance" services. Xu Moumou was responsible for forging nursing confirmation forms, false punch cards, etc., and Zhou Moumou and Chen provided the medical insurance cards of the insured personnel to jointly defraud the "long-term care insurance"**In August 2021, the Shanghai Jiading District Medical Security Bureau found that the nurse Xu Moumou was suspected of defrauding the "long-term care insurance"** amount totaling 4More than 80,000 yuan.
Some caregivers falsely reported their services to deceive **:
Since September 2019, Ji Moumou has worked as an elderly care worker in a family service company, and in accordance with relevant regulations, elderly care workers need to check in and sign out on the designated app before and after door-to-door service, and the insured person will sign and confirm on the service confirmation report, and declare and settle through the designated nursing service agency. In 2022, Ji Moumou took advantage of the APP loophole to turn off the mobile phone positioning function, complete a false check-in in the system, and did not provide services to the elderly, accumulating more than 100 false check-ins, defrauding **1More than 10,000 yuan.
While it is outrageous, these behaviors of sharpening their heads to rub the country's oil, exploiting loopholes, and finding loopholes also remind the medical insurance department that the implementation of long-term care insurance still needs to improve the regulatory details. The author has a few suggestions:
1.Establish a regular re-evaluation mechanism
Although at present, on the basis of the long-term care disability registration and assessment standards and operational guidelines promulgated by the state, each pilot area has established a relatively clear and complete disability assessment standard and assessment process suitable for local needs, and standardizes the "threshold" of the insured's enjoyment of treatment from the aspect of access, aiming to ensure that long-term care is used on those who need it. However, it is undeniable that the disability assessment link is easy to be "faked", and through "acting", some people can deceive the eyes of the assessor and obtain improper benefits - some are spontaneous by the insured, and some are colluded by the nursing institution and the insured.
Judging from the current pilot situation, although many places have set up a return visit or review mechanism in the evaluation process, after confirming the qualifications for treatment, they generally will not deliberately continue to pay a return visit in the follow-up time to review the qualifications, so the "actors" have a chance to take advantage of it. To this end,A re-evaluation link can be established to regularly re-evaluate the insured persons who enjoy long-term care treatment, and try to avoid the situation of "one assessment for life".
2.Make good use of information means and improve supervision
Because the long-term care insurance is to protect the life of the insured after disability, the nursing places are mostly in the family, the nursing content is relatively private, and it is not suitable for "retention certificate" in the form of ** video, etc., coupled with the large population base, wide distribution and easy to disperse, so it is difficult to supervise. The traditional methods of follow-up, shooting, and bracelet positioning are likely to be ineffective, and cannot accurately confirm the service conditions such as nursing time, nursing location, nursing content, nursing object, and nursing quality, which not only cannot meet the regulatory needs of long-term care insurance, but also easily cause dissatisfaction between the insured and their families, and then it is necessary to carry out other forms of supervision through other means. With the development of technology, information technology can play a great role in this process.
As mentioned above, the "whole-process supervision scenario of long-term care insurance assessment service" embedded in the system of Shanghai Transportation Management Center Through the synchronous collection of citizen participation data in the citizen fitness center, combined with the preset early warning rules, the elderly in the comprehensive information database of long-term care insurance are scanned and checked globally, focusing on the elderly who have applied for long-term care insurance services and go to the citizen fitness center for activities, through big data analysis and comparison, the elderly who do not meet the requirements of long-term care insurance are intelligently screened, and their re-evaluation and grading are re-evaluated, so as to empower the mid-stage supervision of long-term care insurance by digital means, and effectively reduce the occurrence of false behaviors in long-term care insurance. There are also many places that use special apps to supervise the work of caregivers, down to the individual, time and location.
At the same time,The existing monitoring methods should be upgraded according to the actual situation of the work. As a regulatory method that is being explored and developed, it is inevitable that "bugs" will appear, such as the case of exploiting app loopholes and falsely reporting services mentioned above, and it is not too late to plug the loopholes in time. But on the other hand, the medical insurance department should try its best to imagine similar "bugs" in advance, prepare in advance, put forward more refined requirements for information monitoring methods, plug loopholes in advance, and try to avoid similar situations when regulatory measures are implemented.
3.Smooth reporting channels
Long-term care insurance fraud presents a more secretive characteristic, and from the perspective of the actual regulatory situation, the clues of many cases are provided by insiders. This reminds health care authorities to make the most of this method and dig up more leads. Improve channels for reporting and complaints, encourage the public to actively report insurance fraud, and may consider giving certain rewards to whistleblowers. At the same time, integrity archives can also be established, the integrity evaluation of insured personnel and nursing institutions, the recording and publicity of insurance fraud, and the punishment of untrustworthy behavior.
In the case that China has entered an aging society, the number of disabled people is increasing, and the importance of long-term care insurance is self-evident, and its development is also expected. However, one of the prerequisites for the development of long-term care insurance must be the smooth operation of long-term care. To maintain safety, the insured themselves should also pay attention to the development of long-term care insuranceConsciously guard the safety of **Until the formation of a common atmosphere in the whole society to protect the safety of long-term care insurance, so that long-term care insurance** can better benefit those in need.
In addition to the above points, the author also suggests that the medical insurance department can promote the construction of the rule of law related to long-term care insurance as soon as possible, and clarify the nature of long-term care. At present, the industry has different perceptions of whether the supervision of long-term care ** applies to the laws and regulations of medical insurance and social security, and even affects the supervision and recovery of long-term care**The healthy development of long-term care insurance urgently needs legal support.
* |China Medical Insurance Yang Zi.
Edit |Fu Meiru Liu Xinyu.
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