The countdown to the national flight inspection has begun, and many large hospitals have been intensively notified.
On December 4, the Hunan Provincial Medical Insurance Bureau issued three administrative penalties one after another, involving three hospitals: Xiangya Hospital of Central South University, Hunan Provincial ** Hospital, and Hunan Provincial Hospital of Integrated Traditional Chinese and Western Medicine.
According to the "Administrative Punishment of Xiangya Hospital of Central South University", from January 1, 2022 to December 31, 2022, orthopedics, hemodialysis, physiotherapy, inspection and laboratory departments and other specialties have illegal use of medical insurance, resulting in a loss 983953 of medical insurance payment72 yuan.
For the illegal use of medical insurance** from January 1, 2022 to December 31, 2022, the amount of medical insurance losses caused by medical insurance will be 9839531 time fine of 72 yuan, 98395372 yuan.
It is understood that Xiangya Hospital of Central South University is a first-class general hospital directly managed by the National Health Commission and an affiliated hospital of Central South University, a university directly under the Ministry of Education. It ranked 13th in the Fudan edition of the 2022 China Hospital Comprehensive Ranking.
According to the official display of the hospital, as of June 2022, the hospital has 3,500 beds, a total construction area of 510,000 square meters, and 347 outpatient and emergency departments in 202130,000 people, 160,000 discharges, 10 surgeries20,000 units. It has established national regional medical centers such as comprehensive and neurology, orthopedics, respiratory, and geriatrics, and has 7 national key disciplines and 25 national key clinical specialties.
The other two notices show that from January 1, 2022 to December 31, 2022, the orthopedics, hemodialysis, physiotherapy, inspection and laboratory departments and other specialties in Hunan Province have illegal use of medical insurance, resulting in a loss of 145617 medical insurance42 yuan. For the illegal use of medical insurance** from January 1, 2022 to December 31, 2022, the amount of medical insurance losses caused by medical insurance ** is 1456171 time fine of 42 yuan, 14561742 yuan.
From January 1, 2022 to December 31, 2022, Hunan Provincial Hospital of Integrated Traditional Chinese and Western Medicine had the problem of illegal use of medical insurance** in orthopedics, hemodialysis, physiotherapy, inspection and laboratory and other specialties, resulting in a loss of 712353 yuan in medical insurance payment. For the illegal use of medical insurance** from January 1, 2022 to December 31, 2022, a fine of 1 times the amount of medical insurance loss of 712353 yuan, totaling 712353 yuan, was imposed.
The 2023 national medical insurance flight inspection is coming to an end, and many places across the country have begun to intensively report cases of illegal use of medical insurance.
In November, the Qinghai Provincial Health Insurance Bureau reported 15 cases of illegal use of medical insurance**, which involved violations by township health centers, pharmacies, individuals, etc.
On December 2, the Anhui Provincial Medical Insurance Bureau notified the Second People's Hospital of Wuhu City of the illegal use of medical insurance. It is understood that the hospital has problems such as excessive diagnosis and treatment, excessive examination, over-prescribing drugs, repeated charges, applied charges, and over-standard charges, involving the total cost of illegal medical treatment21820,000 yuan, of which 18700,000 yuan. The relevant treatments include: first, the full recovery of the illegal use of medical insurance**, and the penalty of 56,074 penalty according to the maximum penalty of 30%.41 yuan; the second is to interview the relevant person in charge of the hospital and order him to rectify immediately; Third, they were handed over to the public security and health departments for further verification and handling.
While verifying the reported issues, the provincial and municipal joint inspection teams conducted a comprehensive extended inspection of the hospital's use of medical insurance** from April 1, 2022 to May 31, 2023, and are currently being further verified.
In September this year, the Sichuan Provincial Medical Insurance Bureau issued the "Sichuan Province 2023 Illegal Use of Medical Insurance ** Cases (Phase II)", involving excessive standard charges, repeated charges, collusion charges, DRG points payment for high sets of points, sales of prescription drugs without a prescription and other illegal use of medical insurance**.
In the same month, the Guangdong Provincial Medical Insurance Bureau**Guangdong Province in 2023 was the second batch of typical cases of illegal and illegal use of medical insurance**, and a number of hospitals, community health centers, and pharmacies were notified.
At the national level, the National Health Insurance Bureau has a total of 4 typical cases this year, involving illegal acts such as falsifying hospitalization, falsifying medical records, forging bills, falsely prescribing diagnosis and treatment items, falsely prescribing medication and doctor's orders, falsely entering the warehouse, and using medical insurance cards in a false name. The notification targets include the insured, hospitals, hospital staff, designated retail pharmacies, enterprises, etc.
In the process of medical insurance supervision, the reporting reward system is an important clue for medical insurance inspection, and the relevant departments pay close attention to the reports of the masses.
Sichuan Province issued a special reminder in the case of illegal use of medical insurance in September this year, "If you find illegal use of medical insurance, please report it to the local or higher medical insurance department in time, and the medical insurance department will reward it according to the regulations after verification, with a maximum reward amount of 200,000 yuan."
In the case of the Second People's Hospital of Wuhu City, the Anhui Provincial Medical Insurance Bureau received a petition report in July this year, reflecting that the Second People's Hospital of Wuhu City used medical insurance in violation of laws and regulations by fictitious, collusive exchange of diagnosis and treatment services, etc. In August, the Anhui Provincial Medical Insurance Bureau and the Wuhu Municipal Medical Insurance Bureau formed a provincial and municipal joint inspection team of more than 20 people to enter the hospital to conduct a comprehensive verification of the hospital charges and medical insurance reimbursement during the informant's father's hospitalization. Through medical record verification, on-site inquiry, data comparison, etc., it was verified that 10 of the 15 problems involved in the report were basically true.
In addition, intelligent supervision methods have refined the granularity of supervision to a new level. Through data screening, analysis and comparison, relevant departments can grasp the abnormal situation more clearly, and then achieve accurate supervision.
In September this year, the National Health Insurance Administration issued the "Notice on Further Promoting the Intelligent Audit and Monitoring of Medical Security", which clarified that by the end of 2023, all areas in the overall planning area will be launched with an intelligent supervision subsystem, and the intelligent audit and monitoring data will be accurately uploaded to the national medical insurance information platform.
With the simultaneous upgrading of the medical insurance supervision model and intensity, it is difficult to get through violations of laws and regulations.