Since the establishment of the National Health Insurance Administration in 2018, from the national level to the local medical insurance departments, a multi-form inspection system combining daily inspections, special inspections, unannounced inspections, key inspections, and expert reviews has been gradually established and improved. In the course of the inspection, various illegal use of medical insurance funds was found, and the author sorted out 38 violations in seven categories for the reference of medical institutions and medical insurance departments.
A_ Chargeable category
A1_ duplicate charges
Interpretation: Repeatedly charge the project fees included in the project connotation.
1. When carrying out "tracheostomy care", the fee of "dressing change and sputum suction" is repeatedly charged;
2. Newborns are repeatedly charged for other levels of care such as "primary care and secondary care" after receiving "neonatal care";
3. Carry out bedside color ultrasound examination, charge the fee of "color Doppler ultrasound routine examination", and then repeatedly charge the fee of "bedside B ultrasound examination";
4. When carrying out "blood cell analysis", the fee of "red blood cell count, white blood cell differential count, and platelet count" is repeatedly charged;
5. When carrying out "stool routine" examination, the fee of "fungal smear examination, fecal parasite egg collection egg microscopic examination, and fecal parasite egg count" is repeatedly charged;
6. When carrying out "bacterial culture and identification", the fee of "general bacterial smear examination, general bacterial culture and identification" is repeatedly charged;
7. When carrying out "general anesthesia", the fees for "sputum suction care and ventilator assisted breathing" are repeatedly charged;
8. After collecting the "intensive care" fee, the special nursing fee (tracheostomy nursing, arteriovenous catheterization nursing, drainage nursing, etc.) is repeatedly charged;
9. When carrying out "rapid paraffin section examination and diagnosis", the fee of "surgical specimen examination and diagnosis" is repeatedly charged;
A2_ break down the charges
Interpretation: The implementation process of the diagnosis and treatment project is decomposed into multiple links and charged one by one.
1. Carry out "percutaneous selective venography" into "percutaneous selective venous catheterization and percutaneous selective venography";
2. Carry out STENT surgery and decompose it into two charges: "percutaneous coronary endoplasty-PTCA" and "percutaneous intracoronary stenting-STENT";
3. Carry out various abdominal surgeries and decompose them into two charges: "laparotomy and XXX surgery";
4. Carry out "transduodenal Oddi's sphincteroplasty" is divided into "transduodenoscopic papillary dilation and transduodenal Audite's sphincteroplasty";
5. Carry out gastroscopy and decompose it into two charges: "fiber esophageoscopy and fiber gastroduodenoscopy";
6. Carry out colonoscopy and decompose it into two charges: "proctoscopy and fiber colonoscopy";
A3_ over-standard charges
Interpretation: Charges will be charged if the price standard and quantity standard exceed the specified price standard
1. Minimally invasive surgery, eye surgery and other small incision dressing changes will be charged for "major dressing changes, extra-large dressing changes";
2. The daily charge for "oxygen inhalation" exceeds the cost of "continuous oxygen inhalation";
3. The number of beds charged exceeds the number of days of hospitalization;
4. The unit price of the diagnosis and treatment items of public medical institutions exceeds the price approved by the government;
5. Both mammography targets are charged at full price;
6. The fee for "surgical specimen examination and diagnosis - additional charge for each exceeding the base price" is more than 90 yuan;
7. "Blood oxygen saturation monitoring and finger pulse oxygen monitoring" are priced according to "times".
A4_ Collusion Charges
Interpretation: Items that do not have a charging standard, but they are replaced with the name and price standard in the catalog for charging; or do not implement the charging price standards of original drugs, diagnosis and treatment items, medical consumables, equipment or medical service facilities; Or the out-of-the-list medical insurance expenses can be converted into in-list expenses for settlement
1. Replace "14×17-inch film (consumables)" with "14×17-inch (diagnosis and treatment items)" to charge;
2. Replace "acupoint application (consumables)" with "acupoint application treatment (diagnosis and treatment items)";
3. Replace the "cooling sticker (consumables)" with "special physical cooling (diagnosis and treatment items)" for charging;
4.将“NT-PROBNP（化学发光法）”串换为“PRO-BNP（各种发光法）”“NT-PROBNP（金标法）”收费；
5. Replace "special medical food" with "nutritional intervention (diagnosis and treatment)" fees;
6. Replace "ultrasonic cutting hemostatic knife head (material fee)" with "ultrasonic cutting hemostatic knife (including knife head and diagnosis and treatment fee)" charge;
7. Replace "microwave therapy (physiotherapy)" with "deep hyperthermia (tumor treatment)" charges;
8. Replace nursing and health education with "guided education and training" or "daily living ability assessment";
9. Replace postpartum rehabilitation with "electronic biofeedback therapy, intermediate frequency pulse electric therapy" and other items; 、
10. Replace the "ultrasound bone density" string with "bone densitometry (nuclear medicine-gamma photography)" fee;
A5_ custom project charges
Interpretation: For projects with no charging standards, self-defined projects and fees. (Public Medical Institutions)
1. Venous repuncture and emergency surgery will be added;
2. Restraint gloves;
3. General sutures (non-absorbable, non-special physical and chemical sutures)
A6_ false charges
Interpretation: forging or altering medical documents or financial bills or vouchers or settlement data, etc.; discrepancies in the purchase, sale and inventory of drugs or consumables; It is not possible to provide the basis for charging for medicines, diagnosis and treatment, consumables, equipment, medical services, and facilities.
1. When carrying out CT examinations, if ECG or respiratory gating equipment is not actually used, the fee of "additional charge for the use of ECG or respiratory gating equipment for CT examination" will be charged;
2. When MR examination is carried out, the fee of "magnetic resonance functional imaging" is charged if the functional imaging is not actually performed;
3. When carrying out CT examination, the cost of "CT imaging" is not actually carried out for 3D reconstruction extraction;
4. When carrying out urine routine examination, the "urine sediment quantification (instrument method)" fee is charged for not actually doing sediment examination;
5. Drugs, reagents, consumables purchase, sales and inventory accounts do not match;
B_ Payment
B1_ pay beyond the scope of medical insurance
Interpretation: Drugs, diagnosis and treatment items, consumables, medical services and facilities beyond the scope of payment of the medical insurance catalog, or beyond the scope of payment agreed by the medical insurance are included in the settlement.
1. Non-children use "chemical granules (oral liquid)" and be included in the medical insurance fund payment;
2. Non-advanced lung cancer patients use "Yilung Qinghua Ointment" and be included in the medical insurance fund to pay;
3. Inpatients with acute non-ischemic cardiovascular and cerebrovascular diseases use "ginkgo darmol (injection)" and be included in the medical insurance fund payment, or use "ginkgo darmol (injection)" medical insurance fund to pay for more than 14 days;
4. Patients with non-hypovolemic shock or significant hypovolemia caused by non-surgical trauma or burns should use "succinyl gelatin (injection)" and be included in the medical insurance fund payment;
B2_ is not paid in accordance with the prescribed proportion
Definition: Violation of the categorical payment ratio or over-limit payment.
1. The proportion of blood albumin payment for a person is 0.8, and the maintenance of medical institutions is 0.9;
2. The proportion of medical insurance payment for a certain consumable is 0.7, and the maintenance of medical institutions is 0.9;
B3_ breach of agreement
Interpretation: Violating the scope of the agreement to include relevant projects in the settlement of the medical insurance fund.
1. The medical expenses incurred by work-related injury patients will be included in the medical insurance fund for payment;
2. The medical expenses incurred in the medical accidents that have been identified by the medical accident appraisal committee will be included in the medical insurance fund for payment;
3. The medical expenses incurred in traffic accidents that have been determined to be responsible will be included in the medical insurance fund for payment;
B4_ other illegal payments
1. Comprehensive training of hemiplegic limbs and other items carried out in a disease cycle for more than 90 days;
2. DRG/DIP settlement cases are not subject to the "three catalogs" regulations.
C_ medical
C1_ repeat treatment
Interpretation: Initiation of treatments with the same or similar mechanism of action.
1. Medium-frequency pulsed electricity and low-frequency pulsed electricity are carried out at the same time in the same part;
2. TCM directional dialysis therapy and ultrasound dialysis in the same part are carried out at the same time;
3. Medium-frequency pulsed electricity and TCM directional dialysis therapy in the same part are carried out at the same time.
C2_ repeat the medication
Interpretation: Simultaneous use of drugs with the same pharmacological effect.
1. Omeprazole injection and omeprazole enteric-coated capsules are used at the same time;
2. Atorvastatin and rivastatin are used at the same time;
3. Ginkgo biloba extract injection and ginkgo biloba should be used at the same time;
4. Shengmai injection and shengmai drink are used at the same time.
C3_ repeat the check
Interpretation: There is no basis for repeated inspections in a short period of time.
1. Carry out multiple glycosylated hemoglobin measurements during the same hospitalization;
2. Multiple examinations of tumor-related antigen tests in the same hospitalization cycle;
3. Biochemistry + electrolyte, blood gas analysis + electrolyte analysis are carried out at the same time;
4. Non-transfusion patients should undergo blood group identification multiple times in one hospital cycle.
C4_ there is no indication for medication
Interpretation: The use of drugs is not related to this hospitalization.
1. Use of antimicrobial drugs in non-infected patients;
2. Patients with non-vitamin deficiency use compound vitamin injection.
C5_ treatment is not indicated
Interpretation: The treatment carried out is not related to the hospitalization.
1. The development of traditional Chinese medicine treatment and rehabilitation treatment has nothing to do with the inpatient/outpatient disease;
2. The indications of TCM physiotherapy are inconsistent with the disease;
3. Acupoint application therapy, auricular acupuncture, electroacupuncture, and traditional Chinese medicine directional dialysis therapy are widely carried out, and there are no relevant records in the course of the disease.
C6_ is not indicated
Interpretation: The examination carried out is not related to the hospitalization.
1. Tumor-related antigen detection for patients with non-malignant tumors;
2. Non-diabetic patients should carry out the examination of "glycosylated hemoglobin determination";
3. Carry out blood infection and blood transfusion related tests for patients with non-transfusion, trauma, surgery, and invasive procedures;
4. No relevant symptoms, signs, or medical history, and routine thyroid ultrasound examination, thyroid function test, gastrointestinal endoscopy and other examinations are routinely carried out in the hospital;
5. Patients without thrombosis risk assessment or thrombosis risk are routinely examined by thromboelastography.
C7_ hospitalization is indicated
Interpretation: Does not meet the indications for hospitalization.
1. Violating the "Clinical Diagnosis and Treatment Guidelines" by admitting patients who can be treated on an outpatient basis to the hospital;
2. The condition is simple and clear, and can be treated with oral drugs and admitted to the hospital;
3. Outpatient surgery for common diseases can be admitted and hospitalized in outpatient or outpatient observation treatment;
4. If the patient only undergoes various examinations, examinations and simple treatment during the hospitalization, the main purpose is health examination;
5. Patients with tumors and strokes who are in stable condition are mainly treated with oral medication after being admitted to the hospital;
6. Excessively exaggerating the harmfulness of the disease to the patient, or inducing the patient to be hospitalized for treatment under the pretext that hospitalization can be reimbursed.
C8_ out of the range of medication
Interpretation: off-label or off-label medication or change of drug route.
1. Non-chemotherapy patients use "palonosetron hydrochloride injection";
2. Non-brain traumatic injury and brain surgery patients use "Citicoline Injection for Injection";
3. Use "ketorolac tromethamine injection" for non-surgical patients in hospitals.
C9_ hospitalized in a hanging bed
Interpretation: Not in the hospital during hospitalization, or in a state of leave for a long time.
1. One bed registers the information of more than two patients at the same time;
2. The body temperature record sheet records "going out" for a long time.
C10_ other violations of diagnosis and treatment routines
1. Diagnosis and treatment exceed the measures recommended by the guidelines.
D_ Recruitment
D1_ offline procurement
According to Article 13 of the Measures for the Management of Medical Consumables in Medical Institutions (Trial), "medical institutions shall select the supply catalogue of their institutions from the centralized procurement catalogue of medical consumables that have been included in the national or provincial and municipal medical consumables"; "Notice of the General Office of the State Council on Printing and Distributing the Reform Plan for the Governance of High-value Medical Consumables" "All public medical institutions must purchase high-value medical consumables on the procurement platform in public transactions and sunshine procurement. ”
D2_ inflated fares
1. Agree with the distributor to purchase drugs and consumables at a discount in the form of a ticket discount;
2. The dealer's invoicing red flush ticket fold part;
3. Adopt the form of "coping" in disguise.
D3_ other violations of the procurement policy
According to the "Reform Plan for the Governance of High-value Medical Consumables", "cancel the addition of medical consumables." The sales of medical consumables in public medical institutions are "zero difference rate", and the sales price of high-value medical consumables is implemented according to the purchase price".
1. Public medical institutions do not comply with the above requirements, and the sales price is higher than the purchase price of the Sunshine Platform;
2. The purchase price of consumables of the same product specification changes, and the medical institution does not adjust the price according to the purchase price;
3. Multiple distributors of the same product specification consumables are purchased at different prices, and sold at the highest purchase price;
4. Offline procurement, sales according to online purchase price;
5. "Gift" consumables into storage, reduce the purchase price in disguise, and sell according to the platform price.
E_ health class
E1_ practice in violation of regulations
Interpretation: Violation of health-related laws and regulations, such as beyond the practice location, scope of practice, practice category, diagnosis and treatment subjects, etc.
1. Western medicine has not obtained the appropriate technology license of traditional Chinese medicine to carry out traditional Chinese medicine treatment, such as acupuncture, small needle knife, etc.;
2. The place of practice is in Hospital A, and the actual practice is in Hospital B, and the cost is included in the medical insurance;
3. Carry out surgical projects beyond the provisions of the practice license;
4. Unqualified to carry out radiological examination and treatment;
5. Carrying out hemodialysis treatment in violation of regulations;
E2_ other violations of health policies
1. In violation of the "Measures for the Management of Medical Consumables in Medical Institutions", the department procures on its own and uses the medical consumables purchased and supplied by the non-medical consumables management department;
2. Failure to establish a regular inventory system for medical consumables, unable to provide "purchase, sale and inventory" data;
3. Failure to sign informed consent when using Class III or implantable medical consumables;
4. Use expired, invalid, obsolete medical devices or medical consumables.
F_ settlement
F1_ break down hospitalization
Interpretation: If the same disease or the same symptom is admitted to the hospital again, the diagnosis and treatment process completed in one hospitalization is decomposed into more than two diagnosis and treatment processes.
1. The surgical process of acute appendicitis is decomposed into three settlements before, during and after surgery;
2. The patient is admitted immediately after discharge, and the patient is not actually discharged;
3. If the patient should be transferred to the department for treatment, the patient shall be discharged from the hospital first for settlement, and then transferred to the department for admission.
F2_ repeated hospitalizations
Definition: Multiple hospitalizations in a short period of time with different diseases or diagnoses.
F3_ select the patient
Interpretation: Select mild cases that are conducive to the "profit" of medical institutions; or prevarication of "loss-making" acute and critical cases that are not conducive to medical institutions.
F4_ low yard high editor
Interpretation: Find and code approximate diagnoses within high-weight reorganization; or by inflating secondary diagnoses according to the MCC/CC table; Or fill in "early diagnosis that has no impact on current hospitalization" and "other diagnosis that has no impact on the consumption of resources in this hospitalization".
F5_ low indication for hospitalization
Interpretation: In violation of the "Clinical Diagnosis and Treatment Guidelines", patients who can be treated on an outpatient basis are admitted to the hospital, patients whose conditions can be treated with oral drugs can be treated mainly with a simple diagnosis, and patients who can be treated with outpatient or outpatient observation and treatment for common diseases in outpatient clinics; If the patient only undergoes various examinations, examinations and simple treatments during the hospitalization, the main purpose is health examination.
F6_ high code low code
Interpretation: Diagnoses are coded to lower-weight recombination and included in the "pay-per-item" settlement
F7_ pass on costs
Interpretation: Let the patient pay the expenses that should be paid by the medical insurance fund at the patient's own expense; or have the expenses incurred in the hospital paid by the patient on an outpatient basis; or the act of asking patients to go outside the hospital to buy.
F8_ unusual ambiguity
Interpretation: In order to reduce the loss rate, select the surgery/operation that does not match the main diagnosis for coding, and enter the "QY group" to pay according to the project for settlement.
G_ other classes
G1_ stolen health insurance card
Interpretation: The person who receives the treatment corresponding to the credit card settlement data is not the cardholder, such as impersonation.
G2_ false settlements
Interpretation: Providing false medical information, diagnosis and treatment information, and fictitious medical service items for settlement.
G3_ did not cooperate with the investigation
Interpretation: Failure to provide relevant inspection materials, electronic data, financial, purchase, sale and storage ledgers as required, intentional destruction or concealment of relevant materials, refusal or obstruction of investigation.
G4_ false propaganda
Interpretation: Advertising with false policies to induce insured persons to purchase drugs and seek medical treatment by swiping their cards.
1. Falsely advertise that the medical insurance card is about to expire;
2. Falsely advertise that personal accounts should be cancelled and the amount of personal accounts should be recovered;
3. The publicity and co-ordination account should expire and expire.
G5_ unauthorized reduction
Interpretation: Reduction and exemption of self-payment, minimum payment line, self-pay fees and other means to induce insured persons to seek outpatient medical treatment and purchase drugs.
Disclaimer: The above views only represent the author's personal opinion, and the specific policies are subject to local policies.
Original title: Fund Supervision | An article talks about all kinds of situations of illegal use of medical insurance funds
Source | Medicare Notes
Edit | Fu Meiru: What to do
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