According to the doctor's self-report, his own scientific research worker, a doctor of law, and also received a little training in economics, this time it was his father who was hospitalized, and he was hospitalized in Wuhu Second Hospital for a total of 117 days, and the medical insurance settlement was 7590,000 yuan, 21 at the patient's own expense90,000 yuan.
In order to better understand each expense, the patient's family has created a daily cost list.
After the abnormality is found, the statistical software is further used to check, and then the abnormal items are listed one by one, and the problem is finally found.
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 for blood purification. The 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**.
The detailed list of expenses shows that the patient received 231 exercises**, totaling 11,088 yuan. In fact, when the patient was hospitalized in Wuhu Second Hospital for 117 days and never accepted the objection raised by his family, the then director of the ICU claimed that he had carried out the exercise, but he could not identify who had carried out the exercise.
3.Suspected of fictitious number of enteral feeder perfusions.
Invoice records show that patients received a total of 1,083 enteral nutrition infusions during the ICU, with an average of 10 perfusions per day21 times. However, according to the Clinical Pharmacy Consensus on Enteral Nutrition (Second Edition), the number of enteral nutrition infusions is 4-6 times a day. From this point of view, if the maximum number of perfusions per day is 6 times, the fee of Wuhu Second Hospital 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 colluding with drugs.
Without the knowledge of the family, the patient was given the most expensive special-use grade antibiotic polymyxin e sodium mesylate (1998 yuan), a total of 8 vials. At that time, it was not in the "National Basic Medical Insurance, Work-related Injury Insurance and Maternity Insurance Drug Catalogue (2022)", and it was a fully self-financed drug, and only polymyxin B (polymyxin) with a similar name was included in the catalog. However, the discharge statement shows that polymyxin e sodium mesylate was settled 15,984 yuan according to medical insurance.
It took two months to analyze. 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 fraudulently and illegally used medical insurance**9586193 yuan-10368193 yuan.
However, what is even more frightening is that this figure is conservative compared to the final survey results.
In August 2023, the results of an investigation by the medical insurance departments of Anhui Province and Wuhu City on this issue showed that the medical insurance** collected by hospitals in violation of regulations during the patient** period accounted for 246%, 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 medical expenses.