Watch Traditional Chinese Medicine Insurance Frauds 3-3》Traditional Chinese Medicine Insurance Fraud Loops Exposed "Looking, Listening, Asking, and Asking" Becomes a Cockroach Vulnerability in Insurance

The diagnostic method of traditional Chinese medicine ("look, smell, ask and feel") essentially relies on the patient's complaint of injury and lacks evidence from objective images and invasive treatments such as Western medicine X-rays and sutures. This feature makes it an "ideal tool" in the eyes of insurance fraudsters. Diagnostic evidence, receipt flexibility and system loopholes have led to many TCM insurance fraud cases in Taiwan in recent years, all of which have accurately exploited this system loophole.

First of all, take the case of Joseph Zhou and his wife as an example. Since 2010, they frequently visited Chinese medicine doctors for reasons such as "falling in the bathroom" and "clamping on the bus", complaining of contusions on their hands and feet. It is precisely through "look, smell, ask, and feel" that Chinese medicine practitioners find it difficult to determine the characteristics of the trauma and require a diagnosis certificate and a receipt for high-cost self-paid medicines. The same contusion accident can lead to up to 132 consultations. He defrauded 14 insurance companies out of 28 million yuan in 12 years.

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Medical insurance and legal personnel believe that the key to this case is that Chinese medicine practitioners are almost unable to refuse diagnosis and treatment to patients with no apparent injuries, and it is difficult to prove that their main complaints are false.

After the case, the Chinese Medicine Practitioners Association also admitted that in the early years, many Chinese medicine practitioners believed patients and issued diagnostic certificates, which put Chinese medicine practitioners at risk of forging documents. This "patient has the final say" diagnosis and treatment model allows insurance fraudsters to bear almost no risk of proof.

Secondly, the amount of self-paid medicine receipts is extremely flexible, making it easy to make false claims. The prices of TCM medicines and health foods paid for by TCM practitioners lack standardization, and the amount on the receipt can be filled in freely. The fake patient pretends to be buying medicines at his own expense, but in fact he is exchanging them for high-priced commodities such as bird's nests and Guilu Erxian glue.

In another case prosecuted by the Taipei District Prosecutor’s Office, an insurance agent named Xie cooperated with a long-term Chinese medicine clinic to exchange medical expenses for health food, massage coupons or 3C products, and then issued receipts with false medical contents, defrauding 7.27 million yuan.

Furthermore, the old duplicate claims system is superimposed on multiple insurance policies, creating room for multiple profits. Fake patients know that they can combine multiple insurance policies through "Duplicate Claims and Actual Payment" to obtain multiple claims. The claim limit for each policy is at least 30,000 yuan. After seeing a doctor, you can repeatedly claim from multiple insurance companies.

The reason why traditional Chinese medicine has become a high-risk field for insurance fraud is the result of the superposition of subjectivity in diagnosis, opacity of receipts, and loopholes in the insurance system. To prevent fraud, in addition to revamping the duplicate claims system, we should also require Chinese medicine practitioners to establish more rigorous injury descriptions and objective supporting records during trauma diagnosis and treatment, so as to reduce the operating space for insurance fraud from the source.