In 2024, the focus of the special rectification of violations of laws and regulations in the medical insurance fund will extend from "fake patients", "fake illnesses" and "fake bills" to violations of laws and regulations hidden in real diagnosis and treatment, and also extend to key areas and key drugs in hospitals, and the connotation of supervision will continue to expand. False medical practices for the purpose of fraud and insurance fraud have always been the focus of the supervision and crackdown of medical insurance funds. In 2024, the special rectification will once again focus on fraud and insurance fraud such as false diagnosis and treatment, false drug purchase, and resale of medical insurance drugs. The following author summarizes the common false behaviors of medical institutions for your reference.
Common false practices in medical institutions
1. False charges
1. False expenses
That is, the examination, inspection, treatment, diagnosis and treatment items or drugs and consumables that have not been carried out will be credited to the basic medical insurance settlement.
Specific manifestations:
(1) The quantity of drugs, consumables, and diagnosis and treatment services is less than the number charged, or the actual number of drugs is not used but there are charges.
(2) If there are no relevant instruments, equipment and facilities or the instruments and equipment have been damaged, the relevant diagnosis and treatment items will be charged.
(3) If there are instruments, equipment and facilities, but they are not used by patients, they will be charged for relevant diagnosis and treatment items.
(4) The charge for a single inpatient diagnosis and treatment item is greater than the length of hospitalization, such as the number of daily billable items is greater than the total number of days of hospitalization.
(5) The billable quantity of medical instruments and equipment related to inspection, inspection, diagnosis and treatment exceeds the maximum workload of equipment or the consumption of consumables.
2. Providing false bills
Medical institutions provide false bills, vouchers or false bills for drugs, consumables and equipment.
Specific manifestations:
(1) Providing false evidence for the gift of drugs and devices for inspection;
(2) Provide false accompanying documents or invoices for inspection;
(3) False issuance of medical service bills.
2. False medical services
1. Seek medical treatment in a false name
Failure to verify the identity of the insured person in accordance with the regulations.
Specific manifestations:
(1) Failure to verify the valid identity credentials of the insured persons and ensure that the certificates are consistent, resulting in others seeking medical treatment in false names;
(2) Inducing or assisting others to seek medical treatment under false names or falsely.
2. Falsification of medical documents
That is, medical institutions and medical personnel use the identity of insured persons to forge or fabricate medical certificates, disease course records, medical orders, surgical records, treatment records, nursing records, prescriptions, examination reports and other medical records, resulting in the loss of medical insurance funds.
Specific manifestations:
(1) Fabricate hospitalization medical records for the insured who has not been hospitalized and reimburse them by medical insurance.
(2) The unimplemented examinations, treatments, surgeries, medicines, consumables and other items shall be reflected in the course of illness records, treatment records, surgical records, prescriptions, etc., so as to increase medical expenses and be reimbursed by medical insurance.
(3) Falsifying medical documents to achieve the purpose of carrying out certain examinations, treatments, surgeries, medications, etc., resulting in the loss of the medical insurance fund.
3. False inspection
The unimplemented inspection and inspection items are included in the medical expense settlement, or the inspection and inspection items included in the medical expense settlement do not have corresponding medical instruments and equipment.
Specific manifestations:
(1) Failure to do relevant inspections and inspections, and issuing false reports.
(2) If there is no medical equipment or testing reagents related to inspection and inspection, the corresponding inspection and inspection project fees will be charged.
(3) If the instrument and equipment have been damaged, there is still relevant billing, and the cost will be included in the medical insurance reimbursement.
4. False treatment
The treatment items that have not been implemented are included in the cost settlement, or the treatment items included in the medical expense settlement do not have corresponding medical equipment and instruments, or the consumption of disposable special consumables involved in the diagnosis and treatment items is less than the billing requirements of the diagnosis and treatment items.
Specific manifestations:
(1) The supporting instruments and equipment for the diagnosis and treatment project, the number of treatment billing, frequency, duration, etc. exceed the workload of the instruments and equipment.
(2) Failure to actually carry out treatment, issuing false treatment execution orders, and including treatment expenses in settlement and medical insurance reimbursement.
(3) If there is no medical equipment related to treatment, relevant treatment fees will be charged.
(4) The implementation of diagnosis and treatment projects is unreasonable. Two or more treatments are performed at the same time at the same acupuncture point. For example, lumbar massage and acupuncture are performed at the same time.
(5) The data of the purchase, sale and inventory account of the primary special consumables involved in the treatment are inconsistent with the billing, and the consumption of consumables is less than the billing of the diagnosis and treatment items.
5. Concealing and fabricating medical conditions
Medical institutions use fictitious causes, exaggerated conditions, fabricated medical history and other means to cause losses to medical insurance funds.
Specific manifestations:
(1) Assist trauma patients to conceal the process of injury, fabricate their medical conditions, and include non-reimbursable medical expenses in medical insurance reimbursement.
(2) Assist patients to include the medical expenses incurred by unpaid diseases into the medical insurance reimbursement.
(3) By exaggerating or inflating the condition, increasing medical expenses, resulting in the loss of the medical insurance fund.
3. False hospitalization
1. Induction of hospitalization
Improper methods are used to induce hospitalization in the form of providing free accommodation, free transportation, free physical examination, reduction or exemption of self-payment and minimum payment of standard fees, cash rebates, rebates, solicitation and recommendation, recharging stored value cards, shopping cards, membership cards, etc., and then fabricating medical services to achieve the purpose of defrauding the medical insurance fund.
Specific manifestations:
(1) Soliciting or promoting insured patients through kickbacks, medical trusts (appointed personnel or through intermediaries), false publicity, etc.
(2) Soliciting or exaggerating the illness of the insured person to be hospitalized through physical examination and free clinic.
(3) Solicit insured persons to be hospitalized by giving away, recharging stored value cards, shopping cards, cash returns, etc.
(4) Soliciting hospitalization of insured persons by providing free accommodation, transportation, and free health examination or treatment.
2. Hospitalization with hanging bed
Hospitalization for patients who do not meet the criteria for hospitalization in order to achieve the purpose of profit, infringing on the medical insurance fund.
Specific manifestations:
(1) After the patient is admitted, the patient is not managed in accordance with the diagnosis and treatment standards of inpatients, and the medical records lack admission records, the first course of illness, doctor's orders and other information.
(2) There is no substantial treatment for a long time during hospitalization, and only outpatient diagnosis and treatment can be completed.
(3) First-level care ECG monitoring or critically ill patients are absent from the hospital without reasonable reasons, and they are discharged from the hospital on continuous leave.
(4) Still working or going to school while hospitalized.
(5) After the patient is discharged from the hospital, he or she is not discharged from the hospital in time, resulting in continuous medical expenses.
3. Bed stacking hospitalization
Hospitalization of two or more patients at the same time in the same bed.
Source | The stronger the culture
Edit | Fu Meiru Liu Xinyu
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