The Hunan Provincial Medical Insurance Bureau recently announced that a number of hospitals have violated the use of medical insurance** and punished the relevant hospitals.
At present, some hospitals do not standardize the use of medical insuranceThere are also individual hospitals that have vicious fraud and insurance fraud. There is no forbidden area for medical insurance supervision, how to protect the people's "life-saving money"?Xinhua Viewpoint reporters launched an investigation.
Some hospitals use Medicare in violation of regulations**.
In the first half of 2023, the Hunan Provincial Medical Insurance Bureau inspected Xiangya Hospital of Central South University and other subordinate and provincial public hospitals and found that Xiangya Hospital had irregular behaviors that deviated from the implementation of ** policies in terms of medical service behavior charges, which is a general violation in accordance with the current medical insurance regulatory laws, regulations and policies.
In the same batch, similar problems were also detected in Hunan Provincial Hospital of Integrated Traditional Chinese and Western Medicine and Hunan Provincial ** Hospital.
The reporter learned from the Hunan Provincial Medical Insurance Bureau that some medical personnel did not fully understand the "Catalogue of Current Medical Service ** Projects in Hunan Province (2022)", and there were illegal use of medical insurance**.
For example, if the medical staff of the hospital finds that the patient has intestinal polyps during the colonoscopy, they will charge the cost of colonoscopy and the removal of intestinal polyps at the same time as the intestinal polyps are removed. According to the current catalogue of Hunan Province, if the cost of intestinal polyp removal is charged, the colonoscopy fee should not be charged at the same time, which is a general illegal use of funds.
Xiangya Hospital uses more than 2 billion yuan of medical insurance every year, and the medical insurance department used more than 980,000 yuan of medical insurance in 2 weeks, accounting for about 4/10,000 of the annual medical insurance use ratio. Zhang Mianchang, deputy director of the Hunan Provincial Medical Insurance Bureau, said that after the incident, Xiangya Hospital took the initiative to return the fees collected in violation of regulations.
According to experts, compared with the general illegal use of medical insurance**, fraud and insurance fraud in the form of repeated charges and excessive medical treatment are more egregious.
Recently, the family of a patient in Wuhu City, Anhui Province reported that they were overcharged by the Second People's Hospital of Wuhu City. The reporter learned from the Anhui Provincial Medical Insurance Bureau and Wuhu City that after verification, 10 of the 15 problems involved in the report are basically true, and the Second People's Hospital of Wuhu City has problems such as excessive diagnosis and treatment, excessive inspection, etc., involving a total of 21 illegal medical expenses820,000 yuan, of which 1870,000 yuan.
Announcement on the official website of Wuhu Medical Insurance Bureau.
At present, the Wuhu Municipal Medical Insurance Bureau will deal with it according to the agreement: first, the full amount of the medical insurance used in violation of the regulations will be recovered, and the penalty of 56,074 will be deducted according to the 30% cap41 yuan;The second is to interview the relevant person in charge of the hospital and order him to immediately rectify the situationThird, they were handed over to the public security and health departments for further verification and handling. At the same time, the administrative punishment procedure for the Second People's Hospital of Wuhu City is underway.
Experts said that the medical insurance department generally has two ways to deal with the problem of illegal use of medical insurance by hospitals. One is the agreement processing, that is, the above-mentioned multiple treatment measures, which is characterized by rapid and timely, which is conducive to the medical insurance as soon as possible to stop the loss. The other is administrative punishment, which generally varies from 1 to 5 times the amount of medical insurance loss depending on the nature of the problem, which is characterized by strong punitiveness, but due to the need to perform procedures such as case filing, on-site inspection, complete collection of evidence, legal review, and notification before punishment, the timeliness of processing is low.
What are the "tricks" of fraud and insurance fraud?
Since the establishment of the National Health Insurance Administration, it has taken various measures such as unannounced inspections, special rectification, big data supervision, and social supervision to strengthen the supervision of medical insurance. From January to October this year, the national medical insurance department inspected a total of 67 designated medical institutions50,000 and 30 institutions dealing with violations of laws and regulations30,000 families, and 136 medical insurance-related funds were recovered100 million yuan.
Industry insiders pointed out that some places are still relatively lagging behind in terms of medical insurance safety awareness and regulatory means, and there is a phenomenon of "running and leaking" in medical insurance, and insurance fraud is more hidden.
The reporter's investigation found that individual medical institutions carried out fraud and insurance fraud through excessive medical treatment, hospitalization, drug exchange, and inducement of patients.
Over-medical, over-prescribing. After adopting policies such as zero markup of drugs to solve the problems of using medicine to maintain medical care, some designated medical institutions have pushed up medical costs through unreasonable examinations and medications, resulting in expensive medical treatment for patients and increasing the burden of medical insurance expenditure.
Bed hanging, hospitalization, false**. Individual medical institutions admit patients who do not meet the conditions for admission, hang beds to reimburse outpatient expenses, and even hypothetical and empty hospitalizations. According to the typical cases of local insurance fraud announced by the National Health Insurance Administration, Harbin Qicai** Hospital had behaviors such as hanging beds for hospitalization, exceeding the scope of practice, and forging medical documents from September 2022 to March 2023, involving the illegal use of medical insurance ** more than 1.49 million yuan.
Collusion of medicines, clever names. Individual medical institutions use "loopholes" such as complicated medical consumables to carry out serial exchange and over-standard fees, etc., and some medical institutions tamper with patients' genetic test results to induce patients without indication to use targeted drugs.
Induce collusion between patients and doctors. Some medical institutions use physical examinations, rebates and other methods to induce insured persons to be hospitalized, and take the opportunity to defraud insurance. In July 2021, when the staff of the Sui County Medical Insurance Bureau in Shangqiu City, Henan Province, reviewed the patient's medical treatment materials in other places, they found that the hospitalization materials of individual local residents in Beixu Xiaoyang Hospital in Linying County, Luohe City were suspected of falsifying medical records. After investigation, the hospital induced patients to be hospitalized by means of free accommodation and car pick-up, and falsified patients' medical records to defraud medical insurance**.
Protecting medical insurance** requires multiple efforts.
Overall, with the deepening of the inspection and supervision of medical insurance bureaus at all levels, the use of medical insurance in medical institutions is becoming more and more standardized. In order to further guard the "safety valve" of medical insurance, it is necessary not only to use intelligent means, but also to strengthen the construction of the supervision team and improve the safety awareness of medical insurance.
The interviewed experts generally believe that to improve the supervision of medical insurance, it is necessary to use information technology to change "finding problems and punishing them afterwards" to "moving the regulatory threshold forward and giving early warning".
According to reports, from January to October this year, the country has passed the intelligent audit and monitoring of medical insurance, and has refused to pay and recovered 20500 million yuan;The big data model was used to screen for false hospitalizations and other violations, and the national medical insurance system verified and recovered funds1200 million yuan.
Tang Feng, director of the medical insurance bureau of Changsha County, Hunan Province, and other heads of grassroots medical insurance departments said that the primary medical insurance departments have limited manpower, and in the face of many medical institutions, they should use information technology to realize the transformation of first-class supervision to all-round, full-process, and full-link intelligent monitoring of big data.
For example, when the medical insurance department finds that the doctor enters "blood cell analysis" and "hemoglobin measurement" at the same time through the smart medical insurance system, it will remind the doctor whether there is a possibility of double charges, and send it to the hospital administrator at the same time.
The director of the Public Economics Research Office of the Chinese Academy of Social Sciences said that the medical insurance supervision policy is strong and professional, and some unreasonable and even illegal acts are not easy to identify, and many insurance fraud methods are hidden, but at present, many local medical insurance regulatory professionals are lacking, and there is no professional law enforcement team, which is difficult to form a continuous deterrent, "It is recommended to build a full-time regulatory team and continue to improve the ability of regulatory law enforcement."
The president of a tertiary hospital suggested that the efficiency of medical insurance should also be considered, the linkage of medical insurance, medical treatment, and medical science should be promoted, and the scientific use of medical insurance should be promoted. (Reporter Peng Yunjia, Shuai Cai, Dai Wei).