Associations operating the medical care system for patients aged 75 or older in Tokyo and 33 other prefectures overcharged the central government a total of ¥1.34 billion (S$15 million) as part of its share of high-cost medical care benefits, The Yomiuri Shimbun has learned.
The fact came to light during inspections by the Board of Audit of Japan.
Under the current system, if the fees owed by an individual to a medical institution exceed the upper limit set for personally borne medical expenses, the portion over the limit is eligible for reimbursement as a high-cost medical care benefit. The overcharges were mainly the result of associations reporting duplicate charges based on medical treatment expense statements from doctors. The board plans to call on the Health, Labor and Welfare Ministry to have these associations return the overpaid money to national coffers.
Insured persons aged 75 or older are required to pay 10 per cent of medical treatment expenses at medical institutions. The rest is covered by tax revenues, pension premiums paid by working generations and other financial resources.
To run the system, all municipalities join a prefectural association that oversees payments for the reimbursable expenses to medical institutions. If an individual's fees exceed ¥800,000 on a single medical treatment expense statement due to serious diseases or other reasons, the high-cost medical care benefits will be partly shouldered by the central government and relevant prefectural government to reduce the financial risk for the associations.
The board examined the costs footed by the central government over the three years until fiscal 2012. It found that when associations calculated the amount to be requested of the central government, they did not exclude the amount of money carried on medical treatment expense statements that had been returned to medical institutions due to insufficient paperwork. Instead, they added the amount to figures carried on the statements that were resubmitted, causing the same statements to be counted twice.
Meanwhile, under the current scheme, if an insured person who suffers serious injury from a traffic accident or other reasons receives a compensation payment from a party at fault, the associations must deduct the amount of compensation from his or her medical treatment expense statement before making a request to the central government. However, the board found that some associations did not follow the rule.
The overpaid money has accumulated in the respective associations, but neither the central government nor the associations were aware of the situation.
The central government can also be held responsible for the problem. When the new system started in 2008, it was discovered that an electronic processing system recommended by the health ministry had an operational problem that could cause the associations to count the statements twice. In addition, the ministry has failed to adequately explain the rule of deducting compensation payments from medical treatment expenses.
"We can't avoid criticism that we weren't sufficiently aware," said an official at Osaka Prefecture's association of medical care services for those aged 75 or older, which was found by the board to have overcharged the central government.
According to the association, it had continually overcharged the government since the system's launch in fiscal 2008. In fiscal 2012 alone, there were about 2,200 cases involving incorrect counting, resulting in about ¥60 million in excess charges.
"It had never occurred to us that we might make mistakes in our calculations," the official said.
Kanagawa Prefecture's association also overcharged the central government a total of ¥230 million over the five years until fiscal 2012 due to miscalculations and mistakes in deduction rules.
"We did not fully understand the new scheme. However, if the central government had given us more information, such mistakes could have been prevented," said an official at Hyogo Prefecture's association, which is currently investigating its own tabulations.