On July 18, 2023, the Anhui Provincial Medical Security Bureau received a petition report from Yang Moumou, 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 during his father's hospitalization due to cerebral hemorrhage**.
On December 3, the Anhui Provincial Medical Security Bureau issued a notice on the incident, the full text of which is as follows:
On July 18, 2023, our bureau received a petition report from Yang Moumou, reflecting that the Second People's Hospital of Wuhu City used medical insurance in violation of laws and regulations during his father's hospitalization due to cerebral hemorrhage through fictitious and collusive exchange of diagnosis and treatment services**. Our bureau attaches great importance to it, and on the basis of doing a good job in data screening and analysis, on August 8, a provincial and municipal joint inspection team of more than 20 people was formed with the Wuhu Municipal Medical Insurance Bureau to enter the hospital to conduct a comprehensive verification of the hospital charges and medical insurance reimbursement during the hospitalization of the whistleblower's father. 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.
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. In order to maintain the safety of medical insurance and protect the legitimate rights and interests of patients, according to the medical insurance service agreement signed between the hospital and the Wuhu medical insurance department, the Wuhu Municipal Medical Insurance Bureau first handled it according to the agreementThe 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% ceiling41 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 present, all the above treatment measures have been completed. At the same time, the Wuhu Municipal Medical Insurance Bureau has initiated the administrative penalty procedure in accordance with the "Regulations on the Supervision and Administration of the Use of Medical Security". While verifying the reported issues, the provincial and municipal joint inspection teams drew inferences from one case to another, and conducted a comprehensive extended inspection of the hospital's use of medical insurance** from April 1, 2022 to May 31, 2023.
On September 25, the Wuhu Municipal Medical Insurance Bureau gave written feedback to the whistleblower in the form of a regulatory notice in accordance with the "Implementation Rules for the Handling of Reporting Clues for the Supervision and Management of Medical Security in Anhui Province (Trial)". In accordance with the "Anhui Provincial Measures for Rewarding Whistleblowers of Illegal Use of Medical Security", 5364 was given to the whistleblower04 yuan reward for reporting. We welcome all sectors of society to supervise the use of medical insurance in designated medical institutions, and we will deal with the problems seriously and will not tolerate them.
Anhui Provincial Medical Security Bureau, December 2, 2023.
[Previously reported].
In November this year, a patient's family member provided a special medical insurance supervision notice to the Economic Observer.
The notice reads:The medical insurance departments of Anhui Province and Wuhu City recovered 18690,000 yuan of medical insurance**, penalty 560,000 yuan;The Second People's Hospital of Wuhu City refunded 3120,000 yuan of out-of-pocket expenses for patients.
On November 28, the relevant staff of the Wuhu Municipal Medical Insurance Bureau and the Second People's Hospital of Wuhu City confirmed the above information to the Economic Observer. At present, the medical insurance bureau has transferred the case to the public security organs and health departments for handling.
What is special about this case of illegal use of medical insurance** is that it only involves one patient, and it was detected by the patient's family in the form of a statistical model and confirmed by the medical insurance department.
The patient spent 117 days in the intensive care unit (ICU) of Wuhu Second People's Hospital for cerebral hemorrhage**, and the medical insurance settlement was 7590,000 yuan, 21 at the patient's own expense90,000 yuan.
After the statistical model analysis of the hospitalization data, the family found that the hospital was suspected of using medical insurance in violation of laws and regulations, such as fictitious medical service items, over-prescribing drugs, repeated charges, collusion of drugs, and including medical expenses that are not within the scope of medical insurance into medical insurance.
This analysis process took two months. In July 2023, the patient's family reported to the National Health Insurance Administration based on the results of statistical model analysis: The medical staff of the Second People's Hospital of Wuhu City at least defrauded and violated the use of medical insurance**9586193 yuan-10368193 yuan. Compared to the final survey results, this figure is still conservative. In August 2023, the results of a survey by the medical insurance departments of Anhui Province and Wuhu City on the issue showedThe medical insurance ** collected by the hospital in violation of regulations during the patient** period accounts for 24 of the total medical insurance reimbursement6%, while overcharging the individual patient by 166% of medical expenses. In the end, the Wuhu Medical Insurance Bureau of Anhui Province recovered 18690,000 yuan of medical insurance**, penalty 560,000 yuan;The Second People's Hospital of Wuhu City returned the whistleblower 3120,000 yuan of out-of-pocket expenses for patients, that is, the Second People's Hospital of Wuhu City overcharged 2180,000 yuan for medical expenses.
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