Vichen.
A report on "A Patient's Family in Anhui Finds Out That a Tertiary Hospital Overcharged 100,000 Medical Expenses, Investigation Shows Overcharge of 210,000" has attracted attention a few days ago.
On December 3, the Anhui Provincial Medical Security Bureau issued a notice stating that 10 of the 15 problems reflected in the patient's family Yang Moumou's petition report were basically true, and the Second Hospital of Wuhu had problems such as excessive diagnosis and treatment, excessive inspection, and over-prescribing drugs, involving a total of 21 illegal medical expenses820,000 yuan, of which 18700,000 yuan. At present, the Wuhu Municipal Medical Insurance Bureau has completed the processing measures according to the agreement: fully recover the medical insurance used in violation of the regulations** and deduct the liquidated damages of 5 according to the 30% cap610,000 yuan, interview the relevant person in charge of the hospital, and hand it over to the public security and health departments for further verification and processing. According to the Economic Observer, the investigation results of the medical insurance departments of Anhui Province and Wuhu City on the issue showed that in addition to the first part of the medical insurance, the Wuhu Second Hospital returned the whistleblower 3120,000 yuan of out-of-pocket expenses for patients.
*The focus on this matter falls on medical insurance**, after all, this is the people's "medical money" and "life-saving money". In the process of two-month analysis, it was discovered that the hospital used medical insurance in violation of regulations, and then reported to the Medical Insurance Bureau, which is somewhat "pulling out the radish and bringing out the mud".
Relying only on the unilateral power of the medical insurance department, it is difficult to discover the mutated insurance fraud behavior of "wearing an invisibility suit" and "hiding in a green gauze tent". This incident also enlightens the medical insurance department to continuously improve the ability to accurately investigate and deal with the problems behind the patient's clues, and mobilize the masses to participate in the supervision of medical insurance.
The verification process is very "high-energy": first, Yang Moumou's aunt (old accountant) made the expense list into excel**, and calculated the approximate proportion of self-payment every day according to the relevant policies of medical insurance payment, and then Yang Moumou (doctor of law, also trained in economics) used statistical software to focus on the period and project with rapid rise and large fluctuations, and then found the unreasonableness.
The other side of "high energy" is what many netizens are worried about: there are no accountants who are sensitive to data, there are no legal people who know how to compare relevant regulations, and they can't do panel data analysis to analyze changing trends - how can ordinary people prevent it?Yang Moumou said, "My mother told me that the families of other ICU patients quarreled with the medical staff, saying that the ICU overcharged money, and finally returned a few thousand yuan. "This may be the state of most people, hazy and hazy feeling that the charge is wrong, but I don't know that ** is wrong, how to verify, who to reflect, and the confusion is over.
This matter does not have much significance for patients and their families, and does not mean that it does not have for the regulatory authorities. The former is not the main body to investigate and deal with medical chaos such as arbitrary fees and insurance fraud, and the rectification of chaos should not be pinned on individuals, but should rely on a normal and long-term regulatory mechanism. Yang Moumou used statistical software to find ** items with abnormal fluctuations, and then compared the number recorded in the three materials of doctor's orders, nursing records, and expense lists for verification. Drawing on this idea, the regulatory authorities also have the advantage of making it easier to obtain more comprehensive data, which is not only convenient for accurately targeting violations of laws and regulations, but also solves the contradiction of a wide range of supervision, a large workload and a shortage of regulatory manpower.
If the regulatory authorities continue to make efforts in making full use of patient clue feedback and implementing real-time dynamic intelligent monitoring of big data, it may not be only "Yang Moumou" who can change the outcome of the matter, and ordinary people can only suffer dumb losses.