Economic Observer reporter Zhang YingOn November 30, the Economic Observer Network reported that after the family of a patient in Anhui found out that the tertiary hospital overcharged 100,000 yuan in medical expenses, the survey showed that it was overcharged by 210,000 yuan, many readers were confused about the hospital's charging items and wrote to ask the patient's family how to verify the medical expenses. Here's what the patient's family had to say:
I'm a researcher, a J.D., and I have a little bit of training in economics. It was my father who was hospitalized in the Second People's Hospital of Wuhu City (hereinafter referred to as the "Second People's Hospital of Wuhu").
My father was a patient in the uremia stage of diabetic nephropathy and needed regular dialysis on March 19, 2022 due to sudden left muscle weakness with impaired consciousness, and his family could not call him, and was urgently sent to Wuhu Second Hospital, where he was diagnosed with thalamic hemorrhage and ruptured into the ventricles, and then transferred to another hospital for further ** on July 12, 2022, and finally died in the early morning of October 14, 2022 at the age of 54 due to ineffective medical treatment.
Dad was hospitalized in Wuhu Second Hospital for a total of 117 days, underwent three craniotomy operations, and has been in a deep coma in the ICU (Intensive Care Medicine Department) of the hospital for most of the time, and his family cannot accompany him or see him.
Discover clues to violations
It was my mother and aunt who first discovered clues about the suspected violations of laws and regulations in the Wuhu Second Hospital. My mom has to go to the hospital outside the ICU gate every night to wait for ** to get a clean towel for my dad, and every time, she asks "How is my lover doing today?" Are you on dialysis? ”
My aunt is an old accountant who pays the hospital bills every day. Every time she pays the fee, she will ask the ** of the ICU to make a list to see the balance of the fee above. After accumulating dozens of lists, my aunt made an excel sheet and calculated the approximate proportion of her own expenses every day according to the national medical insurance catalogue and the relevant policies of Wuhu City's medical insurance payment.
Excluding surgery, when dialysis is not needed, my dad needs to pay 1,000 yuan per day for the maintenance of ** in the ICU; In the case of hemodialysis and continuous blood purification, you need to pay 2,000 yuan per day. In addition to daily expenses, almost all of our family's income is spent on my father's **.
This estimation was valid two months before my father was hospitalized, but since June 14, 2022, the then director of the ICU and ** have taken turns to call my aunt, saying that the money in the account is not enough, and the money must be paid, otherwise it will affect **. Sometimes I call ** in the morning and say that I owe money, and after I pay it, I call ** in the afternoon and say that I owe money. My aunt felt very unreasonable, and went to the medical insurance window of the Citizen Service Center several times, and the staff also said that they had not encountered this situation, and suggested asking the Medical Insurance Office of the Second Hospital of Wuhu.
Figure: An excel sheet made by the aunt of the narrator.
On July 1, 2022, my mom told me that the families of other ICU patients had argued with the medical staff, saying that the ICU had overcharged and ended up returning thousands of dollars. Listening to the family member say that I could see the daily consumption details in the hospital, I knew that there was such a thing, and for the first time I bound my father's ID number, hospitalization number and mobile phone number on the hospital's WeChat.
On July 5, 2022, I was hospitalized through the hospital *** and cleared it for one day" Seeing that there was a charge entry for hemodialysis monitoring, my mother and my aunt asked the attending physician if my father had hemodialysis that day when they went to pick up and deliver clothes, and the reply was no. We had some doubts.
When my father was discharged from the hospital, I found that the total amount of insulin on the "Detailed List of Expenses" was as high as 138, and the average daily dose was 118 insulins, which is clearly out of line with common sense. The insulin in Wuhu Second Hospital is 400 units, and my dad usually uses a maximum of 48 units a day at home, especially the "Nursing Record" shows that my father's insulin** is pumped, even according to the amount of 1 per day, it is also 21 more than 21. This deepens our suspicions.
In addition, my dad had been suffering from uremia for many years and had no urine for a long time, but the "one-day hospitalization" indicated that he would need to have a urinary catheter and an indwelling urinary catheter.
Therefore, on July 12 and July 13, 2022, that is, the day and the next day of my father's transfer, we went to Wuhu Second Hospital to copy and seal all the medical records, and after checking them with the originals, the hospital stamped the official seal, in line with Article 16 of the Regulations on the Prevention and Handling of Medical Disputes, so there was a relevant basis for the subsequent verification of expenses.
Verification using statistical software
I first entered the information on the paper invoices, detailed lists and "hospitalization day clearing" into excel one by one, in excel, I sorted each **item according to the date, made a panel data, first tried to intercept the ** project for a period of time, and used statistical software to analyze the change trend of each item, focusing on the period and project with fast rise and large fluctuations.
Through the trend chart, I can quickly find the ** items and related items with abnormal fluctuations, without the need for regression analysis. Among them, the items with large fluctuations include hemodialysis, antibiotics, etc.
Figure: The change graph that the narrator initially tried to draw using excel.
After locating the ** items with abnormal fluctuations, and then carefully comparing the number of medical orders, nursing records, and expense lists, it was quickly found that there were unreasonable points.
1.Suspected of fictitious hemodialysis monitoring time
In addition to the previously mentioned hemodialysis monitoring time on July 5, on May 17, the hemodialysis monitoring time was 14 hours longer than the blood purification time.
The total time spent on hemodialysis monitoring is 6975 hours, and the continuous blood purification time is 433 hours, only when doing blood purification does you need to do hemodialysis monitoring, but my dad's hemodialysis monitoring time turned out to be 1 of the continuous blood purification time6 times more, the extra cost is 10,580 yuan.
2.Suspected fictitious patient receiving exercise**
During my father's hospitalization, the "Detailed List of Expenses" showed that he received 231 exercises**, totaling 11,088 yuan. In other words, my dad was hospitalized for 117 days and received an average of 2 times a day**, even in the perioperative period after surgery on March 19, April 6 and April 7, 2022 - the patient's critical state is an absolute contraindication, which is obviously inconsistent with the facts. Moreover, the medical records such as "Disease Course Record", "Long-term Medical Order", "Temporary Medical Order" and "Nursing Record" have never recorded or even mentioned any ** items.
Movement is a project carried out by the Section. In fact, at the request of our family, the attending physician did not issue an invitation for consultation until June 30, 2022, but the ** medical department consulted on July 1, 2022 and believed that my father at that time "had abnormal blood clotting routines, a high risk of bleeding, and **contraindications", and suggested that the blood coagulation routine should be actively corrected and reviewed, and then contact the ** department. As of July 12, 2022, my father was hospitalized in Wuhu Second Hospital for 117 days and never accepted***
At the time of our objection, the then director of the ICU claimed that the campaign was carried out, but could not identify who carried it out.
Inventory of items with large fees
In addition, I also checked the items and drugs with high unit prices and high fees based on all medical records.
1.Suspected of fictitious number of enteral feeder perfusions
In the ICU, my dad was in a coma and needed an indwelling gastric tube for enteral nutrition infusion, which was pumped. During the 117 days of hospitalization, except for the failure of enteral nutrition perfusion for 3 days before admission, the suspension of enteral nutrition perfusion for 7 days due to gastrointestinal bleeding, and the 1 day of discharge, enteral nutrition perfusion should have been used for 106 days, and the invoice records showed that my father received a total of 1083 times of enteral nutrition perfusion, with an average of 10 perfusions per day21 times.
Correspondingly, the invoice list recorded that my father used a total of 187 bottles of enteral nutrition suspension (TPF and SP models) during his hospitalization, and the "Disease Course Record" and "Nursing Record" recorded that there was a lot of discarded liquid in enteral nutrition perfusion every day. Under these circumstances, it was extremely unreasonable for my dad to receive more than 10 infusions of enteral nutrition per day. Because according to the "Consensus on Clinical Pharmacy of Enteral Nutrition (Second Edition)", the number of enteral nutrition perfusions is 4-6 times a day.
From this point of view, if the maximum number of perfusions per day is 6 times, the fee of Wuhu Second Hospital exceeds 23,460 yuan. If it is calculated according to 4 times of perfusion per day, the fee of Wuhu Second Hospital exceeds 31,280 yuan.
2.Suspected of collusion in drug exchange
Without the knowledge of our family, my father was given the most expensive special use grade antibiotic polymyxin e sodium mesylate (1998 yuan), a total of 8 sticks. This grade of antibiotic has obvious or serious adverse reactions and should not be used arbitrarily. There are many reports of nephrotoxicity caused by polymyxin (colistin) drugs, and my dad has uremia in the first place.
At the same time, a test report sheet of a similar time period to the use of polymyxin E sodium mesylate showed that the "colistin" drug susceptibility test with a name similar to "polymyxin" was "intermediary", while the inexpensive amikasin (amikacin) drug susceptibility test that the hospital had and my father used repeatedly later showed that it was "sensitive" (note: sensitivity refers to the drug is the most effective for patients, and the intermediary refers to general sensitivity, and the effect is uncertain).
Later, I submitted a request to the Wuhu Municipal Administration for Market Regulation for verification on polymyxin e sodium mesylate**, and the bureau investigated and said that the drug was temporarily purchased by the hospital.
Article 13 of the Regulations on the Prevention and Handling of Medical Disputes stipulates that if it is necessary to carry out clinical trials and other special examinations that are dangerous and may have adverse consequences, medical personnel shall explain to the patient's close relatives and obtain their written consent when the patient is in a coma or other state where the patient is unable to make a decision on his own or his condition is not suitable to explain to the patient.
Article 62 of the Detailed Rules for the Implementation of the Regulations on the Administration of Medical Institutions stipulates that "medical institutions shall respect patients' right to know about their own conditions, diagnoses, and diseases." Necessary explanations should be given to patients during surgery, special examinations, and special examinations. Where it is inappropriate to explain the situation to the patient due to the implementation of protective medical measures, the patient's family shall be notified of the relevant circumstances." Paragraph 4 of Article 88 clearly stipulates that special examinations and special examinations include "examinations and examinations whose fees may cause a greater financial burden to patients".
I also found that polymyxin e sodium mesylate was not in the "National Basic Medical Insurance, Work-related Injury Insurance and Maternity Insurance Drug Catalogue (2022)" at that time, and it was a fully self-financed drug, and only polymyxin B (polymyxin) with a similar name was in the catalog. But my father's discharge statement shows that polymyxin e sodium mesylate was settled for 15,984 yuan according to medical insurance.
The process of asserting rights
It took me more than two months to analyze the medical expenses of Wuhu Second Hospital. It is estimated that the Second Hospital of Wuhu and medical staff fraudulently and illegally used medical insurance**9586193-103681.93 yuan.
Since August 2022, we have negotiated with Wuhu Second Hospital on the cost issue three times, and the hospital said that it had organized a self-inspection, and said that there were discrepancies between the quantity of some drugs and the settlement details in the second doctor-patient communication, and that it would further verify it, but denied it in the third communication.
In July 2023, I reported it to the National Health Insurance Administration. In August 2023, the Anhui Provincial Medical Insurance Bureau and the Wuhu Municipal Medical Insurance Bureau carried out an inspection of the Wuhu Second Hospital.
On August 10, 2023, the law enforcement inspection team of the Anhui Provincial Medical Insurance Bureau and the Wuhu Municipal Medical Insurance Bureau met with me and my relatives to report the preliminary investigation results, and recognized many of the problems I reported, but said that the investigation and punishment were different from the details I listed. I would like to express my respect for the Working Group's investigation as a non-health care professional, but have reservations about some specific details.
On September 25, 2023, the Wuhu Medical Security Regulatory Affairs Center delivered me the "Notice of the Processing Results of the Supervision Clues of the Wuhu Medical Security Bureau", which clarified that "the medical insurance department recovers 186914".7 yuan medical insurance**" at the same time asked the Wuhu Second Hospital to refund 31287$29 out-of-pocket expenses for patients.
At present, the Wuhu Municipal Medical Insurance Bureau first deals with the Second Hospital of Wuhu in accordance with the "Interim Measures for the Management of Medical Security Designated Points in Medical Institutions", which is based on departmental regulations. However, they also said that they would "deal with it in accordance with laws and regulations according to the inspection situation". The national laws "Social Insurance Law", "Basic Medical Care and Health Promotion Law", and the administrative regulations "Regulations on the Supervision and Administration of the Use of Medical Security" all stipulate that administrative penalties should be imposed for violations by the hospitals and medical personnel involved.
In the process of my father's **, I personally experienced the major benefits brought by the national medical insurance policy to ordinary people, so I hated the behavior of illegally obtaining medical insurance ** and infringing on the people's "life-saving money". In my opinion, even if it does not involve insurance fraud, in accordance with the principle that laws and regulations are higher than departmental rules and regulations, and the lower law is subordinate to the superior law, administrative penalties should be imposed on the illegal use of medical insurance. The relationship between agreement and administrative punishment is not "one or the other", and there is no contradiction between making an administrative penalty after the agreement is made. I am still in communication with the Wuhu Municipal Medical Insurance Bureau on this matter.
*: The Economic Observer.