In the medical insurance flight inspection announced by the National Health Insurance Administration, a total of 48 designated medical institutions will be randomly inspected in 2022, and the second major problem found in the inspection is the exchange of drugs, consumables, diagnosis and treatment items and service facilities, among the 48 medical institutions spot-checked, 46 hospitals have such problems, and the violation rate is as high as 9583％。The managers of medical institutions or the medical insurance office understand that "collusion" is a more serious violation of medical insurance, and deliberate "collusion" to obtain medical insurance** involves fraud and insurance fraud, therefore, many hospitals will not and dare not carry out "collusion". So why is the violation rate of "collusion" so high during medical insurance flight inspection?
In addition to the conscious "collusion", more unconscious "collusion" is the fundamental reason for the "collusion" violation in hospitals. The reason for the emergence of unconscious "collusion" is caused by the inaccuracy of the hospital medical insurance code.
The reason for the appearance of unconscious "cascade".
The medical insurance code matching personnel did not carefully distinguish when carrying out the medical insurance standard and code matching, but only selected the code for the root drug name. The following is illustrated by the case of a drug.
*Click to enlarge it.
Through the above figure, it can be found that the same drug, the specifications, manufacturers, and national drug quasi-brand size are the same, but the packaging specifications and quantities are different, and the drugs are different. If the medical insurance code checker does not accurately check the code according to the actual purchase and use of the standard dose of the hospital, there will be inaccurate code matching.
Through Figure 2, it can be seen that the same manufacturer of drugs, drug specifications, different national drug quasi-brand sizes, and different drug **. Similarly, the dosage form of the drug is different, and the drug** is naturally different.
Whether it is a drug or a consumables classification and coding database, the implementation of dynamic maintenance, each maintenance involves some drugs or consumables** out of use or new or changed. However, the hospital does not carry out dynamic maintenance of the code, and it is usually used after the code, without checking or checking.
The accuracy of the medical insurance code has not been verified. The daily in-hospital medical insurance quality control or self-inspection only pays attention to the rectification of clinical violations, and ignores the verification of the medical insurance code.
What are the common code matching problems in hospitals?
Drug code matching
1. The specifications of the drugs used in the hospital are inconsistent with the specifications of the code, such as the specifications of the hospital drugs are 031g*24 pieces; Match code specification 03g*14 tablets.
2. The drug manufacturers used in hospitals are different from the manufacturers of codes. For example, if the hospital purchases drugs from pharmaceutical company A, the code is pharmaceutical company B.
3. The dosage form of the hospital drug is inconsistent with the dosage form of the code. For example, the drug purchased and used by the hospital is atorvastatin calcium tablets, and the code is atorvastatin calcium capsules.
The drug specifications and manufacturers are incorrect, and it is not easy to be found through big data comparison, but it is easy to "expose" the on-site inspection. The drug dosage form does not match the code, and the big data supervision can be directly exposed.
Chinese medicine decoction pieces are coded
1. The use of traditional Chinese medicine decoction pieces in hospitals is inconsistent with the Chinese medicine decoction pieces with the right code. The hospital uses traditional Chinese medicine decoction pieces for forging keel (T111801300), and the code is keel (T001400507), although there is only a word difference, but due to different processing methods, Chinese medicine decoction pieces ** are completely different.
2. If the code is wrong, the code of A Chinese medicine decoction piece will be B Chinese medicine decoction piece. The wrong code matching of drugs will lead to a discrepancy between the number of Chinese medicine decoction pieces in the medical insurance settlement and the purchase, sale and inventory of the hospital. The number of billing, medical insurance settlement, and the number of prescriptions issued.
Consumables are coded
Taking the commonly used intravenous indwelling needle in clinical practice as an example, it is not difficult to find: (1) Even if the classification, material, and registration number of consumables from the same manufacturer are the same, the characteristics are different, and the consumables are different.
2) Consumables of the same manufacturer, the classification, material, and characteristics are the same, the registration number is different, and the consumables code is different.
*Click to enlarge it.
Common code matching problems in medical institutions:
1. The specifications of consumables used in the hospital are inconsistent with the specifications of the code;
2. The hospital procurement consumables manufacturers are inconsistent with the code manufacturers;
3. The actual consumables used in the hospital are inconsistent with the code consumables, that is, the A consumables are matched to B consumables.
Diagnosis and treatment item code matching
1. High reliance on testing methods, that is, the testing methods charged by hospitals for codes are inconsistent with laboratory testing methods. For example, the national code of the high-density lipoprotein cholesterol determination project is: 002503030040000, and the connotation of the project is: dry chemical method, and other methods are reduced. If the hospital test is not a dry chemical method, it should be used: Serum HDL cholesterol measurement (other methods) (002503030040200). If the hospital uses the original item** for medical insurance settlement, there will be a problem of "concatenation" of test items.
2. The diagnosis and treatment items used by the hospital are inconsistent with the settlement items of the code matching items. For example, if the hospital uses a blood glucose meter to measure the blood sugar of the patient, the code settlement item is: computer blood glucose monitoring.
Summary
The medical insurance code is not as simple as everyone imagines, and the code is not accurate, resulting in abnormal settlement data, and the hospital will inevitably avoid the "collusion" violation in the face of medical insurance audit. Code personnel must pay attention to the details when carrying out medical insurance standard matching and accurately distinguish the code. Don't ignore the management of medical insurance codes anymore.
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