A scientific research worker, a doctor of law, also learned some economic knowledge, and used statistical software to estimate that the Second Hospital of Wuhu fraudulently obtained and used medical insurance in violation of regulations**9586193-103681.93 yuan.
Hospitals may never have imagined that they would be able to analyze their vulnerabilities with statistical software. Therefore, the communication between the doctor and the hospital is not smooth. The doctor had no choice but to report to the National Health Insurance Administration.
After investigation, the Wuhu Second Hospital overcharged more than 210,000 yuan. Among them, 1869147 yuan medical insurance**, 31287$29 out-of-pocket expenses for patients.
After the incident, the majority of netizens sighed, "The book is really not read in vain".
If the patient is not a scientific researcher, does not understand the law, and has not studied economics, can he analyze the overcharge charged by the discharger?
Let's see what happened, how the doctor found out about the hospital's cattiness.
On March 19, 2022, the doctor's father, who was in the uremia stage of diabetic nephropathy and required regular dialysis, was rushed to Wuhu Second Hospital due to sudden left muscle weakness with impaired consciousness, and was diagnosed with thalamic hemorrhage and rupture into the ventricles.
Finally, due to ineffective medical treatment, he passed away in the early morning of October 14, 2022, at the age of 54.
Dad was hospitalized in Wuhu Second Hospital for a total of 117 days, underwent three craniotomys, and has been in a deep coma in the ICU (Intensive Care Medicine) of the hospital for most of the time, and his family could not accompany him or see him.
The doctor's aunt was an old accountant who was responsible for paying the hospital's bills. After paying the fee each time, let ** type a list. After accumulating more than a dozen lists, I made an excel sheet and calculated the approximate proportion of my own expenses every day according to the family medical insurance catalog and the relevant policies of Wuhu City's medical insurance payment.
When dialysis is not required, Dr.'s father needs to pay 1,000 yuan per day to maintain ** in the ICUIn the case of hemodialysis and continuous blood purification, you need to pay 2,000 yuan per day.
In the first two months, this calculation was more accurate. Starting on June 14, 2022, the fees began to increase. Sometimes, **in the morning, I called** to let me pay, and after paying the fee, I called ** in the afternoon and said that I was in arrears.
The doctor's mother also heard that some of the patients' family members were arguing with the hospital and saying that they were overcharged.
All kinds of signs can't help but make people careless.
The doctor bound his father's ID number, hospitalization number and mobile phone number on the hospital's WeChat***. In this way, the doctor can check the charges of the relevant items through the hospital***.
On July 5, 2022, Dr. saw a charge entry for hemodialysis monitoring through *** hospitalization one-day clearance. My aunt and mother (details, two people) asked the attending physician if my father had hemodialysis that day, and they replied no.
It is now almost certain that the hospital is overcharged.
When my father was discharged from the hospital, 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. When the doctor's father was at home, he used a maximum of 48 units a day, while the one in Wuhu Second Hospital was 400 units. In total, the hospital dosage is more than 10 times the household dosage.
On July 12, July 13, 2022, which is the day and the next day of Dad's transferWe went to the Second Hospital of Wuhu to copy and seal all the medical records, and after checking them with the originals, the hospital stamped the official seal, in line with the provisions of Article 16 of the Regulations on the Prevention and Handling of Medical Disputes, so there was a relevant basis for the subsequent verification of fees.
First of all, the paper invoices, detailed lists and the information on the "hospitalization day clear" are entered into excel one by one, in excel, I sorted each **item according to the date, made a panel data, first try to intercept the ** project for a period of time, and use statistical software to analyze the change trend of each item, focusing on the period and project that rises quickly and fluctuates greatly.
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.
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
The total time spent on hemodialysis monitoring is 6975 hours, while the continuous blood purification time is 433 hours, and hemodialysis monitoring is only required when doing blood purification, 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 his hospitalization, the "Detailed List of Expenses" showed that he received 231 exercises**, totaling 11,088 yuan. In other words, my father was hospitalized for 117 days and received an average of 2 times a day of exercise**, 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", "Nursing Record" and other medical records have never recorded or even mentioned any ** items.
3.Suspected of fictitious number of enteral feeder perfusions
In the ICU, the father was in a coma and needed an indwelling gastric tube for enteral nutrition perfusion, which was pumped. During the 117 days of hospitalization, excluding 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 discharge for 1 day, enteral nutrition perfusion should have been used for 106 days, and the invoice records showed that the father received a total of 1083 times of enteral nutrition infusion, with an average of 10 perfusions per day21 times.
It is extremely unreasonable for a father 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 times of enteral nutrition is 4-6 times a day.
If the maximum number of perfusions per day is 6 times, the fee of the Second Hospital of Wuhu 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.
4.Suspected of collusion in drug exchange
Without the knowledge of the 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 father already has uremia.
Polymyxin E sodium mesylate was not included in the National Catalogue of Drugs for Basic Medical Insurance, Work-related Injury Insurance and Maternity Insurance (2022) at that time, and was a fully self-financed drug, and only polymyxin B (polymyxin) with a similar name was included in the catalog. According to the discharge statement, polymyxin e sodium mesylate was settled 15,984 yuan according to medical insurance.
It took more than two months for the doctor to analyze the medical expenses of the Second Hospital of Wuhu. It is estimated that the Second Hospital of Wuhu and medical staff fraudulently and illegally used medical insurance**9586193-103681.93 yuan.
To this end, the patient's family made three representations with the Second Hospital of Wuhu, and the first two times, the hospital said that it would conduct internal inspections. The third time, the opinion of the family was simply denied.
In July 2023, the doctor reported 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 September 25, 2023, the Wuhu Medical Security Regulatory Affairs Center delivered the "Notice of the Processing Results of the Supervision Clues of the Wuhu Medical Security Bureau" to the doctor, clarifying 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 Designated Management of Medical Security in Medical Institutions", which is based on departmental regulations.
We ordinary people may not have a doctor's knowledge, but if we carefully check the hospital's charges, we can still find out the abnormal charges. For example, insulin use, exercise**, and hemodialysis tests.
The most important thing is to be sure to apply the law.