On December 27, 2023, Jinan City released the cross-examination of medical insurance ** jointly carried out by five ministries and commissions, focusing on three aspects, including:Orthopedics, Blood Purification, Cardiovascular Medicine, Examination, Examination, Physiotherapyand other key areas, the top key drugs and consumables in the medical insurance settlement costs, as well as key behaviors such as false medical treatment and reselling of medical insurance drugs.
It is understood that this is the first time that Jinan City has carried out cross-inspection of districts and counties, in accordance with the principle of "double random and one open", to determine the grouping of participating districts and counties and inspected districts and counties, and according to the use of medical insurance in each district and county, from the top 5 medical institutions and social medical institutions, and the top 3 long-term care institutions, each randomly selected 1 institution as the inspection object.
Jinan City has established a joint conference system for medical security supervision with the participation of eight departments, including medical insurance, procuratorate, development and reform, public security, finance, health, market supervision and taxation, to improve the inter-departmental coordination mechanism. In particular, in the verification of the suspicion issued by the National Health Insurance BureauFalse hospitalization OverdoseWhen waiting for clues, a data comparison mechanism has been established with the public security department to ensure the accuracy of clue verification.
At the same time, Jinan City divides the functions and processes of intelligent supervision before, during and after the event. In particular, in advance, it was installed at the end of the designated medical institution, and a total of it was set upRational drug use, catalogue restrictions, chronic disease regulations, medical management, audit and refinement, and disease reviewand 134 rules in 6 categories, real-time reminders of pharmaceutical service behaviors, and a total of 6,191 unreasonable diagnosis and treatment items and drug expenses will be blocked in 2023180,000 yuan.
In recent years, medical insurance inspection has become one of the important matters for medical institutions to welcome inspections, especially at the district and county level, municipal level, provincial level and national level, which has become an important measure for strong supervision in the medical field.
In March 2023, the National Healthcare Security Administration issued the departmental regulation "Interim Measures for the Administration of Unannounced Inspections of Medical Security", which stipulates the principles, starting conditions, organizational methods, inspection requirements, inspection procedures, and problem handling of unannounced inspections. Subsequently, the National Health Insurance Administration issued two documents, the "Notice on Carrying out the Special Rectification Work on Combating Fraud and Insurance Fraud in the Field of Medical Insurance" and the "Notice on Carrying out the Unannounced Inspection of Medical Security in 2023" in April and July respectively, making medical insurance administrative law enforcement a regulatory norm and bringing challenges to medical institutions to cope with medical insurance inspections.
According to reports, on August 8, 2023, a provincial and municipal joint inspection team of more than 20 people formed by the Anhui Provincial Medical Insurance Bureau and the Wuhu Municipal Medical Insurance Bureau was stationed in the Second People's Hospital of Wuhu City. After investigation, the hospital had 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 treatment 21820,000 yuan, of which 18700,000 yuan.
According to the medical insurance service agreement signed between the hospital and the Wuhu Municipal Medical Insurance Department, the Wuhu Municipal Medical Insurance Bureau handled the agreement in advanceThe first is to recover the full amount of the medical insurance ** used in violation of regulations, and deduct the penalty of 56,074 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.
According to the Beijing News, the illegal use of medical insurance by the Second People's Hospital of Wuhu City has also exposed the compliance risks of the hospital in the use of intensive care departments and medical insurance.
There are many forms of compliance risks in the diagnosis and treatment of intensive care units, and there are also different situations involving the illegal use of medical insurance**, such asHospitalization, over-standard charges, duplicate charges, over-prescribing and re-prescribing, deprection, decomposition of hospitalization, decomposition of charges, collusion of drugs, medical consumables, diagnosis and treatment items and service facilities, excessive examination, excessive diagnosis and treatment, fictitious medical servicesand so on.
If a medical institution is found to have fraudulently obtained medical security**, on the one hand, it will bear administrative penalties and suffer heavy economic lossesOn the other hand, judicial cases can also be used to get a glimpse of the process and results of medical insurance administrative law enforcement, and then put forward standardized suggestions for medical institutions to respond.
Establish a structure and build a system.
Determine the responsibilities of the school agreement
First of all, medical institutions should establish an organizational structure and a medical insurance management and self-inspection system in accordance with the law, and clarify the responsibilities of medical insurance functional departments and relevant clinical departments.
In order to avoid the risk of relevant administrative penalties, the internal control self-inspection system of medical institutions should comply with the relevant provisions of Article 14 of the Regulations on the Supervision and Administration of the Use of Medical Security: designated medical institutions shall establish an internal management system for the use of medical security, and specialized institutions or personnel shall be responsible for the management of the use of medical security, and establish and improve the assessment and evaluation system. Designated medical institutions shall organize and carry out training on relevant systems and policies of medical security, regularly inspect the use of medical security in their units, and promptly correct the irregular use of medical security.
Secondly, medical institutions should be familiar with the service agreement of designated medical institutions for medical security.
The service agreement of the designated medical institution for medical insurance involves the decomposition of many professional terms related to the supervision and management of the use of medical security** such as hospitalization, excessive diagnosis and treatment, and excessive examination, especially the terminology of medical insurance violations ranging from 1 to 5 times.
For example, the concept of "set charges" in the service agreement of a designated medical institution for medical security in a certain place is clearly stipulated, that is, the set charge refers to the use of other charge items to charge because there is no charge standard for a certain diagnosis and treatment item.
At the same time, the service agreement of designated medical institutions for medical security also clearly stipulates the applicable objects, pharmaceutical management, liability for breach of contract, etc., which can deepen the identification of medical insurance violations, and provide guidance for clinical operations and improve relevant systems and processes through policy and agreement interpretation and training, especiallyInformed consent, diagnosis and treatment records, and information disclosureand other matters to avoid or reduce the administrative risk of medical insurance in medical institutions.
Provisions on administrative penalties for medical insurance
Don't be unfamiliar!
In the past three years, the state has issued a series of regulations on medical security, and various provinces and cities have successively improved the administrative law enforcement procedures and discretionary benchmarks for medical insurance.
Combined with the disclosure of medical insurance administrative punishment information, such as the relevant typical administrative punishment cases released by the National Health Insurance AdministrationThere is an objective situation that confuses the general breach and the fraud and insurance fraud, and it is also controversial whether it is classified as fraud and insurance fraud, and after the medical institution is inspected, it will impose penalties on medical insurance, such as refunding the lost principal and giving 2 times or 5 times the penaltyMost medical institutions do not have the right to be heard, and even fewer have filed administrative reconsideration or administrative litigation
After searching, since the "Regulations on the Supervision and Administration of the Use of National Medical Security**" came into force on May 1, 2021, not a single administrative lawsuit has been retrieved (it is not excluded that the judgment documents may not be made public). Based on this, medical institutions can respond from the following three aspects:
First, it is necessary to combine the relevant provisions on administrative processing. In addition to learning and understanding the medical insurance regulatory regulations, medical institutions also need to adjust and change the provincial and municipal medical insurance catalogs and medical insurance catalogs, learn and update them in a timely manner, prepare hospital documents, organize clinical department learning, and do a good job in the disclosure of medical service information, so as to avoid problems such as untimely adjustment of provincial and municipal medical insurance inspections and national flight inspections, and improve the effectiveness of self-inspection.
The medical insurance management department and the specific leaders in charge of medical institutions should change their thinking about medical insurance management, and change the current passive mode of simply handling medical insurance settlement and post-event rectification to promoting and guiding clinical medical insurance complianceProactive mode
Second, be familiar with the administrative inspection and handling procedures of medical insurance.
For example, after the unannounced inspection clues are transferred to the medical security department where the medical institution is located, the local medical security administrative department should file a case for investigation, and improve the administrative law enforcement procedures in combination with the unannounced inspection clues, such as on-site inspection and investigation, and form the investigation record and on-site inspection record of the territorial medical insurance department.
Third,When medical institutions respond to inspections and treatments, they can pay attention to whether law enforcement personnel have law enforcement qualifications, such as verifying law enforcement certificates, that is, law enforcement personnel need to clearly indicate the law enforcement work certificate to the subject of law enforcement and their staff, rather than just a work card.
At the same time, the relevant inspection documents need to be checked and signed page by page, and law enforcement officers are also required to sign. For the signature column of the person in charge, the information checked should be verified page by page and item by item, especially the violations, including the violations and amounts, and the signature should be signed carefully after checking.
If objections are raised to the evidence relied on by law enforcement personnel, they should be raised in a timely manner, and information technology personnel should be arranged to accompany the information queried through big data in order to verify the authenticity and accuracy of the evidence collection informationPrepare for subsequent argument hearings or even administrative reconsideration or litigation, that is, to enhance the awareness of compliance of medical insurance administrative law enforcement, and be familiar with the provisions of medical insurance law enforcement procedures, so as to safeguard their legitimate rights and interests and avoid or reduce administrative risks.
Fourth, where administrative penalties may be involved, especially if there are objections to the characterization of the violation and the amount of the penalty, on the one hand, the legal rights of the administrative counterpart shall be fully exercised, such as making statements and defenses and applying for a hearing;On the other hand, for the amount and qualitative aspects, seek legal remedies in a timely manner, including the early intervention of legal counsel and legal counsel.
The qualitative nature of general violations and fraud and insurance fraud should be correctly interpreted, and the amount of violations should be verified in order to reduce and reduce or avoid losses to the greatest extent, so as to avoid the risk of dereliction of duty caused by the negative response of the person in charge and the competent leader to the loss of assets of the medical institution.
To sum up, medical institutions should strengthen pre-prevention, in-process control and post-event relief in response to medical insurance law enforcement, have an organizational structure, clarify responsibilities, have systems, strengthen training and learning, and improve the effectiveness of medical insurance legal provisions and policy applicationUpdate in a timely manner and carefully summarize each inspection to avoid repeating mistakes.
In the event of an administrative disposition, do a good job of post-event relief from the perspective of procedure and substance, and protect their own lawful rights and interests in accordance with the law. It is suggested that a medical insurance compliance system for medical institutions can be actively established to reduce management costs, reduce the risk of medical institution management performing duties, and avoid the loss of state-owned assets.