According to a report on February 3, multiple psychiatric hospitals in Xiangyang and Yichang, Hubei province, have been improperly admitting patients by offering promises of "free hospitalization and free transportation," and are suspected of defrauding medical insurance funds through methods such as fabricating medical services, which has attracted widespread attention.
On February 3, authorities in Xiangyang and Yichang separately issued notices stating that they had established task forces or joint investigation teams to conduct comprehensive investigations. On February 4, the official "Hubei Release" account responded, announcing that Hubei province had formed a joint investigation group to address media reports concerning some psychiatric hospitals engaging in "improper patient admissions and suspected medical insurance fund embezzlement."
On February 4, the National Healthcare Security Administration issued a notice to conduct collective interviews with designated medical institutions for psychiatric diseases covered by medical insurance. The notice specified that all designated psychiatric institutions must complete self-inspections and rectifications by March 15, submit written reports, and refund any illegally obtained medical insurance funds. The focus should include, but not be limited to, inducing hospitalization, false admissions, fabricating conditions, inventing treatments, forging documents, and charging improper fees—all illegal activities related to medical insurance fund usage.
Several experts interviewed indicated that insurance fraud in psychiatric hospitals is actually not uncommon in China and occurs more frequently in private psychiatric facilities. What are the underlying systemic and regulatory reasons behind the repeated occurrence of such incidents? How can more effective regulatory mechanisms be established to prevent the erosion of medical insurance funds?
Why is insurance fraud so frequent? Journalists found that in recent years, medical insurance departments at the provincial, municipal, and county levels in Liaoning, Guangdong, Jiangxi, and other regions have reported typical cases of psychiatric hospitals improperly using medical insurance funds or being suspected of fraud.
In 2023, relevant personnel from the Hunan Provincial Medical Insurance Bureau and other institutions published an article in the "China Health Insurance" magazine, pointing out that from 2019 to 2021, Hunan province conducted 447 surprise inspections on psychiatric specialty medical insurance funds, identified 1,670 problems, with a 100% issue discovery rate among inspected institutions; seven institutions had their medical service agreements suspended, and one had its agreement terminated; a total of 80.8062 million yuan in medical insurance fund losses was recovered, with administrative penalties amounting to 15.5977 million yuan.
In December last year, Heyuan City, Guangdong province, exposed five typical cases of improper medical insurance fund usage, three of which involved psychiatric hospitals improperly using medical insurance funds. The three hospitals involved were all private, for-profit psychiatric specialty hospitals, with improper usage totaling approximately 1.21 million yuan.
In 2022, the Liaoning Provincial Medical Insurance Bureau announced a special rectification action targeting five designated psychiatric hospitals, primarily addressing issues such as exceeding approved bed quotas, settling non-psychiatric patients under per-diem rates, waiving deductible fees, and unreasonable charges. During the campaign, a total of 812 approved beds were reduced for the five psychiatric hospitals, budget indicators were adjusted by 3.7052 million yuan, institutions self-reported 287,500 yuan in违规 funds, and an additional 615,400 yuan in违规 medical insurance funds was identified and recovered.
In November 2024, the Jingdezhen City Medical Insurance Bureau in Jiangxi province announced that it had investigated and dealt with insurance fraud involving several private psychiatric hospitals, including Fuliang Jianning Psychiatric Hospital, recovering a total of 3.4801 million yuan in medical insurance funds.
Why is insurance fraud so prevalent in psychiatric hospitals? Healthcare reform expert Xu Yucai, in an interview, stated that this phenomenon stems from multiple reasons. Firstly, in recent years, private mental health institutions have developed rapidly, but some lack sufficient entry requirements, internal management, and standardized practices, making them more prone to违规 behavior. Under current medical insurance rules, any medical practice that does not conform to standardized diagnostic and treatment requirements may be deemed违规 or even fraudulent, and the operational and definitional aspects of psychiatric diagnosis and treatment make it relatively easier to "cross the line."
Secondly, unlike many other diseases, the treatment process for mental illnesses often involves extensive scale assessments, psychological interventions, and behavioral training—methods that lack clear equipment records like surgeries or imaging tests. Xu Yucai gave an example: if a psychiatric ward with 30 inpatients organizes a group walk in the courtyard, this could be considered and charged as a treatment session in psychiatric care. However, whether the patients actually received effective treatment and whether the intensity met standards is often difficult for medical insurance departments to accurately assess during post-audit checks.
Huang Xiuxiang, former Secretary-General of the Hunan Pharmaceutical Distribution Industry Association, told reporters that in daily supervision, regulatory bodies like medical insurance departments find it difficult to communicate fully with psychiatric patients. Some patients have cognitive impairments or exhibit symptoms like mania or agitation, limiting their ability to express themselves and judge, making it hard for regulators to verify whether the claimed medical services actually occurred based on patient feedback.
Zhong Chongming, former Associate Researcher at the National Health Insurance Research Institute of Capital Medical University, mentioned that the relatively closed environment of psychiatric hospitals creates gray areas in medical billing and reimbursement management, providing space for fraud.
Huang Xiuxiang noted that many psychiatric hospitals do not use Diagnosis-Related Groups (DRG) or Diagnosis-Intervention Packet (DIP) payment models but instead use per-diem payment. Psychiatric patients often require long-term, continuous inpatient treatment. Under this model, the more patients admitted and the longer the hospitalization, the higher the payable medical insurance fees, which can incentivize延长住院或虚假收治, becoming one of the drivers for fraud.
In May 2024, the Hunan Provincial Medical Insurance Bureau disclosed in a reply to a provincial人大代表 that in 2023, the number of psychiatric inpatient settlements under the per-diem payment model in the province was 204,200, a 27% increase from the previous year, accounting for 86.97% of total psychiatric inpatient admissions. The reply also pointed out that while the per-diem model has improved住院保障人次和报销水平 for patients in the chronic phase, daily supervision and special inspections have revealed issues in some institutions, such as fabricating services, providing insufficient actual services, excessive testing, misuse of rehabilitation items, and improper charging, affecting the efficiency of medical insurance fund usage.
Considering that the intensity of psychiatric treatment decreases as the病程 progresses, many regions gradually reduce payment standards at intervals like 30, 60, or 90 days under the per-diem model. Xu Yucai pointed out that the per-diem system itself is a positive incentive, aiming to provide hospitals with a relatively reasonable and predictable payment method. As long as institutions follow standardized treatments, they receive corresponding fees, reducing the motive for illegal profit through fraud. "However, this payment model still needs further refinement."
How can effective supervision be achieved? In recent years, the number of patients with mental disorders nationwide has shown an upward trend, while psychiatric medical resources have continued to expand. Data from the National Bureau of Statistics shows that from 2018 to 2024, the number of psychiatric beds nationwide increased from 63,000 to 77,000.
Several experts pointed out that psychiatric hospitals and related treatment resources remain scarce in China, with overall demand still exceeding supply. Xu Yucai mentioned that precisely because resources are tight, regulators often have significant reservations in practical enforcement. Huang Xiuxiang also stated that relevant departments do want strict supervision but face practical dilemmas: if problematic psychiatric hospitals are intensively investigated and have their qualifications revoked, the subsequent issue is that genuinely needy long-term psychiatric inpatients might have "nowhere to go."
Regarding how to achieve more effective supervision of insurance fraud in psychiatric hospitals, Huang Xiuxiang believes that systematic排查 can start with regional aggregate data. For instance, first check the proportion of medical insurance reimbursements claimed by psychiatric hospitals in a specific area; if a significant portion of the local medical insurance fund flows to psychiatric hospitals, it should raise alerts. Further analysis can examine the overall medical expense share of psychiatric specialty hospitals or psychiatric departments in general hospitals within the region; if it is significantly higher—say, one to two times above the national average for mental health treatment costs—then in-depth verification is necessary. Additionally, he suggested strengthening supervision by analyzing the rationality of usage patterns for psychiatric medications and medical equipment.
He further stated that as long as the medical insurance department's supervision and early warning systems are sufficiently robust, abnormal situations can be detected through data analysis. For example, setting预警指标 for cost structures, length of stay, bed occupancy rates, etc., can automatically trigger risk alerts if significant deviations from norms occur. Such efforts should be spearheaded by medical insurance departments.
Huang Xiuxiang emphasized that administrative supervision alone is insufficient; social oversight and smooth reporting mechanisms are also needed. If investigations confirm cases where individuals are falsely diagnosed as mentally ill and kept on long-term "admission" solely to embezzle insurance funds, sufficiently severe penalties that truly make违规 institutions pay the price should be imposed according to law.
Several interviewed experts also mentioned the necessity to optimize the current medical insurance payment methods for psychiatric patient treatment. In Xu Yucai's view, the prevalent per-diem payment in psychiatry directly links hospitalization duration to hospital revenue. If clinical treatment guidelines could further clarify the boundaries of "what should and should not be done" for different diseases, and situations clearly beyond reasonable ranges were prioritized for supervision, it would be easier to detect fraudulent activities.
Multiple experts also pointed out that addressing the frequent occurrence of insurance fraud in psychiatric hospitals requires coordinated supervision from multiple departments. However, in practice, this coordination is often lacking. The aforementioned article in "China Health Insurance" noted that psychiatric specialty medical institutions involve many administrative departments, and coordination among medical insurance, health authorities, civil affairs, and public security is poor, making effective integration difficult, with unclear responsibility divisions leading to a "three-no-management" phenomenon.
Huang Xiuxiang stated that generally, the establishment and licensing of psychiatric hospitals are primarily managed by health authorities, while the usage and supervision of medical insurance funds fall under medical insurance departments. Simultaneously, civil affairs departments, social assistance, and charitable organizations play important roles in patient aid and保障, and drug regulatory departments are also essential for supervising medication and medical device usage. Psychiatric patients often also involve matters like disability certification, fee reductions, and social assistance, necessitating clear division of responsibilities and concerted efforts at the systemic level.