8 percent of the violations are related to the laboratory department!A number of hospitals were noti

8 percent of medical institutions are related to inspections

Including the big three

On November 27, the Medical Security Bureau of Benxi City, Liaoning Province issued the "Notice on the Violations Discovered by the Liaoning Provincial Medical Security Bureau's Unannounced Inspection of 10 Designated Medical Institutions in Our City in 2022", which notified in detail the various violations found in the 10 designated medical institutions.

According to the Circular, in 2022, the Liaoning Provincial Medical Insurance Bureau organized an inspection team to conduct unannounced inspections of 10 designated medical institutions such as Benxi Hospital of Traditional Chinese Medicine. That is to say, violations were found in the 10 designated medical institutions sampled, and the violation rate reached 100%.

It should be noted that among the 10 designated medical institutions notified, 8 of them were related to inspections, including two tertiary hospitals. Some of the irregularities related to inspections are as follows:

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Benxi Hospital of Traditional Chinese Medicine:

1. Unreasonable charges for B-type natriuretic peptide (including precursors).

2. Unreasonable charges for serum troponin I measurement (no indication examination).

4. Unreasonable charges: unreasonable charges for set examinations, due to the charging of more than two items on the same day, alpha-fetoprotein determination, creatinine determination, serum creatine kinase determination, serum aspartate aminotransferase determination (liver function and cardiac enzyme), serum total protein determination, serum albumin determination (liver function and kidney function), and the part of each charge that exceeds one time is a violation.

5. Unreasonable charges: unreasonable charges for serum bicarbonate determination, due to blood gas analysis and serum bicarbonate at the same time, the latter is a duplicate charge.

6. Unreasonable charges (no indication examination): unreasonable charges for serum-L-fucosidase set (no indication examination), due to the determination of serum -L-fucosidase to exclude the Department of Infectious Diseases, Department of Infectious Diseases, Department of Intensive Care Medicine, and ICU, patients with hepatitis, liver cancer, liver cirrhosis, and liver malignant tumors in the diagnosis are excluded, and the rest indicate no indication examination.

9. Unreasonable charges for hepatitis E measurement (no indication examination).

10. Unreasonable charges for hepatitis A measurement (no indication examination).

11. Unreasonable charges for plasma reagin test, because treponema pallidum specific antibody determination and plasma reagin test are charged at the same time, it is excluded that the diagnosis contains "syphilis", and the plasma reagin test shows violations.

Benxi Kangning Hospital:

4. Serum albumin determination is overcharged for a single day.

5. Creatinine measurement is overcharged in a single day.

6. Serum creatine kinase determination is overcharged for a single day.

7. Serum aspartate aminotransferase assay is overcharged for a single day.

8. Serum total protein determination is overcharged for a single day.

11. Suspected overcharge for calcium ion measurement: data screening for those under the age of 60 who are excluded from diagnosis containing bone, porosity, tumor, cancer, mass, kidney, cost details excluding bone density measurement, department exclusion including tumor, severe disease, hospice care, blood, geriatrics, rheumatism, and other suspected illegal charges.

The Affiliated Hospital of Liaoning University of Traditional Chinese Medicine (Shenben Campus):

4. Determination of B-type natriuretic peptide precursor (Pro-BNP): If the number of B-type natriuretic peptide (including precursors) charged on the same day (the cumulative number of natriuretic peptides and natriuretic peptide precursors can be calculated) is greater than 1, the amount of violation = unit price (quantity-1), and the determination of B-type natriuretic peptide precursor (Pro-BNP) is used in violation of regulations.

11. Repeated charges for serum bicarbonate (HCO3) determination: Serum bicarbonate (HCO3) determination is charged on the same day for blood gas analysis, and the latter is a duplicate charge.

12. The set of examinations involves repeated charges: more than two items are charged on the same day, alpha-fetoprotein determination, creatinine determination, serum creatine kinase determination, serum aspartate aminotransferase determination (liver function and cardiac enzyme), serum total protein determination, serum albumin determination (liver function and kidney function), and the part of each charge that exceeds one time is a violation, and the amount of violation = unit price of the project * (number of charges - 1).

On October 8, the National Health Insurance Administration issued the "Guiding Opinions on Strengthening the Management of Medical Insurance Payment Qualifications of Relevant Personnel in Designated Medical Institutions (Draft for Comments)", which clarified the management objects for the relevant personnel involved in the use of medical security in designated medical institutions, including medical, pharmaceutical, nursing, technical and other health professional and technical personnel who provide medical services for the insured in designated medical institutions.

Once the "Opinions" issued this time are implemented, it means that the supervision of medical personnel will begin, and the punishment will be accurate to the individual. However, the management objects specified in the "Opinions" obviously include inspectors.

It is true that in most cases, the tests performed by the examiner are "what the doctor prescribes, we do", but the punishment does not make the examiner a penalty.

The official document of the province was issued

A total of 16 flight inspections will be carried out in 2023

According to the "2023 Provincial Medical Insurance ** Supervision and Unannounced Inspection Work Plan" issued by the Liaoning Provincial Medical Insurance Bureau on February 24, 2023, the medical insurance flight inspection in Liaoning Province in 2023 has also been carried out from May to the end of September this year.

The work plan clearly states that the scope of the provincial flight inspection is 14 cities, taking the form of "14 + 2", on the basis of carrying out full coverage inspection of 14 cities, Shenyang and Dalian will each be inspected once, and a total of 16 flight inspections will be carried out in the province. In addition, special inspections will be carried out at the same time for the centralized procurement of drugs and consumables. The special inspection of the centralized procurement of drugs and consumables in designated medical institutions will be included in the provincial flight inspection and carried out simultaneously.

It is worth mentioning that the document on the national deployment of the 2023 medical insurance flight inspection work was released in July this year:

On July 15, the National Health Insurance Administration, the Ministry of Finance, the National Health Commission, and the State Administration of Traditional Chinese Medicine jointly issued the "Notice on Carrying out the 2023 Medical Security ** Unannounced Inspection" and issued the "2023 Medical Security ** Unannounced Inspection Work Plan".

In addition, the official launch of the 2023 National Medical Security** unannounced inspection will be on August 23 this year. This also means that Liaoning Province, which issued the "Work Plan" in February this year and carried out provincial-level flight inspections in May, has carried out a "rush".

Up to now, including Liaoning Province, many places across the country have actively responded to the national policy and launched medical insurance flight inspection. According to statistics, more than 20 provinces and municipalities such as Guizhou, Shaanxi, Sichuan, Xinjiang, Shanghai, Hainan, and Shandong have successively launched the 2023 medical insurance flight inspection work.

The state has repeatedly emphasized

Clinical examination is the focus of the examination!

According to incomplete statistics, many of the contents related to medical insurance flight inspection released by the state this year mentioned that clinical testing is one of the key areas of flight inspection work:

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On April 28, the National Health Insurance Administration, the Supreme People's Procuratorate, the Ministry of Public Security, the Ministry of Finance, and the National Health Commission jointly issued the "Notice on Carrying out Special Rectification Work on Combating Fraud and Insurance Fraud in the Field of Medical Insurance", which was officially issued and required the implementation of the "2023 Special Rectification Work Plan for Combating Fraud and Insurance Fraud in the Field of Medical Insurance".

The work measures of the plan are clear, focusing on the key points of rectification, mainly in three aspects, the first of which is to focus on key areas such as orthopedics, blood purification, cardiovascular medicine, examination, inspection, and physiotherapy. It is required to investigate and deal with typical cases of fraud and insurance fraud in the fields of inspection, inspection and physiotherapy through national flight inspection and provincial flight inspection.

The work plan clearly states that this year, three areas of medical imaging examination, clinical examination, and ** will be selected as the focus of inspection.

On August 23, the official website of the National Medical Security Administration issued a document that the 2023 National Medical Security ** unannounced inspection was officially launched, and once again emphasized that clinical testing is one of the three key focus areas of this unannounced inspection.

The state has repeatedly emphasized that the selection of medical imaging examination, clinical examination, and ** as the focus of inspection undoubtedly shows the importance attached to the phenomenon of medical insurance violations in the laboratory department, as well as the frequent occurrence of medical insurance violations in the laboratory department. And in 2021 and 2022, the state's notification of the results of medical insurance flight inspections has also proved this:

In June this year, the National Health Insurance Administration notified the results of the 2022 medical insurance unannounced inspection. According to the report, a total of 48 designated medical institutions that were randomly inspected had the problem of "repeated charges, over-standard charges, and decomposition project charges" in medical insurance violations, of which 39 had the problem of "excessive diagnosis and treatment and excessive inspection in violation of diagnosis and treatment norms".

In the "2021 Announcement on the Unannounced Inspection of Medical Insurance**" issued by the National Health Insurance Administration in May 2022, the phenomena of duplicate charges, over-standard charges, and decomposition project charges are also extremely prominent. Among them, "excessive inspection, decomposition of project charges", etc., are all risk points for testing medical insurance violations.

2021 Medical Insurance ** Unannounced Inspection Violations.

Therefore, the possible medical insurance violations in these laboratory departments are naturally very likely to become the focus of attention during the medical insurance flight inspection in 23 years.

Attached: Medical insurance violations in the inspection and inspection items of medical institutions (due to the difference in medical insurance policies and implementation fees in various places, for reference only).

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01. Carry out"Bacterial culture and identification"In the absence of a clear positive, ** charged"Bacterial culture + routine antimicrobial susceptibility qualitative test"Expenses.

Qualitative problem set charges, over-checking.

Note Without the approval of the competent provincial and municipal authorities, medical and health institutions inspect patients according to the basic combination of inspection and inspection items established by themselves, and charge fees for them, which is an illegal act of forcing and charging fees.

02. Carry out"Fecal routine"When checking, **Check"Stool routine + fecal parasite egg collection ovoscopy + fecal parasite egg count + general bacterial smear examination"and many other projects.

Qualitative problem set charges, over-checking.

03. Carry out"Urinalysis"At the time of the inspection, the set is carried out"Urinalysis + urine sediment quantification""

Qualitative problem set charges, over-checking.

04, will 4$5 times"Routine chemistry urinalysis"The control is 10 yuan"Urinalysis (dry chemical method)."Toll.