Clipping Board » Medical Affairs and Administration ─ Medical system, pharmaceuticals, and medical community-related reports
Update Date: 2010/03/17 16:16 By Hu Zhao-Wei
Taiwan’s National Health Insurance (NHI) system has been highly praised even by Nobel Prize-winning economist Paul Krugman. However, its financial situation is, in fact, dire.
Since 1998, the fourth year after its inception (with the exception of 2000), the NHI has been operating at a deficit—expenditures exceeding revenues. By 2007, the NHI’s reserve funds had been completely depleted, and its cumulative balance turned from surplus to deficit, never to recover.
What’s the reason? The public points fingers at “unfair premium collection.” Yet, when examining the causes behind the nearly 300-billion-NTD black hole in the NHI, the primary culprit is the mismanagement by the Bureau of National Health Insurance (BNHI).
Among these, the largest issue is “fraudulent claims by medical institutions,” amounting to a staggering 164.8 billion NTD. This means that doctors, whose duty is to save lives, are ironically the top offenders responsible for the NHI’s massive financial losses.
How do unscrupulous medical institutions exploit the NHI? The most common method is swiping patients’ NHI IC cards multiple times in a single day and then filing claims on staggered dates. Another tactic involves hospitals billing for services—such as hospitalization, tests, or surgeries—that were never actually provided. Absurd cases have included: doctors allegedly seeing patients while hospitalized themselves, the same tooth being extracted multiple times, men undergoing hysterectomies, and NHI IC cardholders receiving medical treatment while abroad. Even prestigious medical centers like Kaohsiung Medical University Chung-Ho Memorial Hospital have had obstetricians accused of performing unnecessary surgeries on “fake patients” by exaggerating their conditions.
Zhu Xian-Guang, head of the research and development division at the Taiwan Healthcare Reform Foundation, explains that colluding with nursing homes is another way medical institutions fraudulently claim NHI funds. Some hospitals collect NHI IC cards from all residents of a nursing home in advance, then swipe the cards to falsely claim reimbursement for rehabilitation treatments the elderly never received.
How severe is the problem? From 2005 to the present, an average of about five out of every 100 NHI-contracted medical institutions have been caught violating regulations—a shockingly high crime rate. According to the latest report from the Control Yuan, over the past 11 years, the BNHI should have recovered a total of 167.7 billion NTD in fraudulent claims from unscrupulous medical institutions. Yet, only 2.869 billion NTD has been recovered, averaging a mere 260 million NTD per year—a success rate of less than 2%.
The BNHI’s explanation for this is “limited investigative manpower.” However, this “limited manpower” has managed to uncover over 100 billion NTD in fraudulent claims over the past 11 years. So why can’t the funds be recovered? “The cat clearly sees the mouse right there but just won’t catch it,” one scholar bluntly criticized the BNHI’s inaction. “If it’s not negligence, then it’s collusion.”
Moreover, according to the Healthcare Reform Foundation, the process from the BNHI identifying violations, verifying them, announcing penalties, to actually enforcing them takes at least three and a half years. “The drawn-out punishment process emboldens unscrupulous doctors,” said Liu Mei-Jun, executive director of the foundation. Even when clinics face suspension or termination of their NHI contracts, some violators remain unafraid, as they can simply reapply for NHI reimbursement under a new clinic name.The National Health Insurance (NHI), which had accumulated losses of nearly 60 billion yuan by last year, is like a critically injured patient lying in the emergency room. To revive it, merely increasing premiums is not enough—the urgent priority is to address the existing mismanagement issues within the NHI system. Recovering the fraudulent claims made by unscrupulous doctors alone would be enough to wipe out the NHI's accumulated losses up to last year. If the government insists on raising premiums without eliminating deep-rooted problems, it will only provoke stronger public backlash.
Source: http:/ / tw. news. yahoo. com/ art……rl/ d/ a/ 100317/ 116/ 227ml. html
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Taiwan’s National Health Insurance (NHI) system has been highly praised even by Nobel Prize-winning economist Paul Krugman. However, its financial situation is, in fact, dire.
Since 1998, the fourth year after its inception (with the exception of 2000), the NHI has been operating at a deficit—expenditures exceeding revenues. By 2007, the NHI’s reserve funds had been completely depleted, and its cumulative balance turned from surplus to deficit, never to recover.
What’s the reason? The public points fingers at “unfair premium collection.” Yet, when examining the causes behind the nearly 300-billion-NTD black hole in the NHI, the primary culprit is the mismanagement by the Bureau of National Health Insurance (BNHI).
Among these, the largest issue is “fraudulent claims by medical institutions,” amounting to a staggering 164.8 billion NTD. This means that doctors, whose duty is to save lives, are ironically the top offenders responsible for the NHI’s massive financial losses.
How do unscrupulous medical institutions exploit the NHI? The most common method is swiping patients’ NHI IC cards multiple times in a single day and then filing claims on staggered dates. Another tactic involves hospitals billing for services—such as hospitalization, tests, or surgeries—that were never actually provided. Absurd cases have included: doctors allegedly seeing patients while hospitalized themselves, the same tooth being extracted multiple times, men undergoing hysterectomies, and NHI IC cardholders receiving medical treatment while abroad. Even prestigious medical centers like Kaohsiung Medical University Chung-Ho Memorial Hospital have had obstetricians accused of performing unnecessary surgeries on “fake patients” by exaggerating their conditions.
Zhu Xian-Guang, head of the research and development division at the Taiwan Healthcare Reform Foundation, explains that colluding with nursing homes is another way medical institutions fraudulently claim NHI funds. Some hospitals collect NHI IC cards from all residents of a nursing home in advance, then swipe the cards to falsely claim reimbursement for rehabilitation treatments the elderly never received.
How severe is the problem? From 2005 to the present, an average of about five out of every 100 NHI-contracted medical institutions have been caught violating regulations—a shockingly high crime rate. According to the latest report from the Control Yuan, over the past 11 years, the BNHI should have recovered a total of 167.7 billion NTD in fraudulent claims from unscrupulous medical institutions. Yet, only 2.869 billion NTD has been recovered, averaging a mere 260 million NTD per year—a success rate of less than 2%.
The BNHI’s explanation for this is “limited investigative manpower.” However, this “limited manpower” has managed to uncover over 100 billion NTD in fraudulent claims over the past 11 years. So why can’t the funds be recovered? “The cat clearly sees the mouse right there but just won’t catch it,” one scholar bluntly criticized the BNHI’s inaction. “If it’s not negligence, then it’s collusion.”
Moreover, according to the Healthcare Reform Foundation, the process from the BNHI identifying violations, verifying them, announcing penalties, to actually enforcing them takes at least three and a half years. “The drawn-out punishment process emboldens unscrupulous doctors,” said Liu Mei-Jun, executive director of the foundation. Even when clinics face suspension or termination of their NHI contracts, some violators remain unafraid, as they can simply reapply for NHI reimbursement under a new clinic name.The National Health Insurance (NHI), which had accumulated losses of nearly 60 billion yuan by last year, is like a critically injured patient lying in the emergency room. To revive it, merely increasing premiums is not enough—the urgent priority is to address the existing mismanagement issues within the NHI system. Recovering the fraudulent claims made by unscrupulous doctors alone would be enough to wipe out the NHI's accumulated losses up to last year. If the government insists on raising premiums without eliminating deep-rooted problems, it will only provoke stronger public backlash.
Source: http:/ / tw. news. yahoo. com/ art……rl/ d/ a/ 100317/ 116/ 227ml. html