The hospital inspection is in progress, and many provinces are intensively following up
HC3i is a new medical institution
Guide:
Combined with the pilot work of medical insurance anti-fraud big data supervision and application, strengthen the application of drug traceability codes in the supervision of medical insurance funds, explore the construction of multi-dimensional big data models, screen and analyze suspicious clues in hidden data, and promote breakthroughs in big data supervision
In 2024, the medical insurance flight inspection has been officially launched, and Shanghai, Sichuan, Shanxi, Hubei, Guangxi, Shandong, Hebei, Guizhou, Ningxia, Yunnan, Xinjiang, Hainan and other places have intensively followed up.
The National Health Insurance Administration reported that the hospital had cheated on insurance
On May 14, the fourth day of the official launch of the 2024 National Health Insurance Fund flight inspection, the official official account of the National Health Insurance Administration issued a notice on the suspected illegal use of the medical insurance fund by the Disability Health Traditional Chinese Medicine Hospital, and at the same time reprinted the report of Xinhua News Agency in full.
On May 12, Xinhua News Agency's "Xinhua Viewpoint" column broadcast a draft of "Pulling the Five Guarantees for the Elderly to Fake Doctorcare and Fake Hospitalization - Investigation of a Hospital in Shanxi Involved in Insurance Fraud", exposing that the Fenyang Disabled Health Traditional Chinese Medicine Hospital in Luliang City, Shanxi Province induced some rural Wubao elderly people who were not sick or had mild symptoms to be hospitalized. Fenyang City attaches great importance to this, and the local public security organs have taken criminal coercive measures against 10 people.
The picture above is a photo of the Chinese Medicine Hospital for the Disabled. Xinhua News Agency (photo by Yang Zhe on April 29)
According to the circular, the relevant procedures for investigating and dealing with medical insurance violations are as follows:
The Fenyang Municipal Medical Insurance Bureau terminated the medical insurance service agreement of the Disabled Health Traditional Chinese Medicine Hospital and ordered it to carry out a self-examination. After the self-inspection, the Chinese Medicine Hospital handed over the medical insurance fund of 197601 yuan for illegal use. In the follow-up investigation, the Fenyang Medical Insurance Bureau recovered 52,507.19 yuan from the medical insurance fund and imposed a fine of 262,535.95 yuan. Up to now, the loss of the first batch of national medical insurance funds has been recovered 250,108.19 yuan.
It has been found that there are problems with the medical insurance reimbursement amount of at least 8 elderly people in the hospital involved, and the hospital involved has suspended its operation. In addition, other hospitals in the city found that 44 people had abnormal medical insurance reimbursement data.
From self-inspection and self-correction to the suspension of medical insurance to the refund of fees, the whole process was completed within three days, reflecting the high efficiency of the special rectification of medical insurance, and forming a strong deterrent to the objects of such violations.
In 2024, the flight inspection will be launched, and many provinces will start hospital inspections
On May 11, the 2024 unannounced inspection of the National Medical Security Fund was officially launched, and Shanghai, Sichuan, Shanxi, Hubei, Guangxi, Shandong, Hebei, Guizhou, Ningxia, Yunnan, Xinjiang, Hainan and other places also began to follow up.
On May 15, six departments, including the Hubei Medical Insurance Bureau and the National Health Commission, jointly held the 2024 Provincial Medical Insurance Fund Special Rectification Work Conference on Violations of Laws and Regulations.
At the meeting, it was mentioned that it is necessary to focus on false diagnosis and treatment, false drug purchases, reselling medical insurance drugs, and key drug consumables with large amounts of medical insurance funds and abnormal changes.
In response to illegal and criminal acts of fraud and insurance fraud in key areas such as orthopedics, hemodialysis, cardiology, examination, testing, and rehabilitation physiotherapy, we have comprehensively carried out self-examination and self-correction, and continued to promote the rectification of problems.
It is reported that since 2023, Hubei Province has inspected a total of 41,000 medical institutions, dealt with 19,000 designated medical institutions, publicly exposed 1,266 typical cases, transferred 65 judicial organs (people), handed over 382 discipline inspection and supervision organs (people), and recovered, punished, refused to pay and other funds totaling 880 million yuan.
On May 15, Shandong Province proposed that from 2021 to 2023, there will be a total of 109 national and provincial flight inspection designated medical institutions, including 99 designated medical institutions at the second level and above. This year, we will focus on intensive care medicine, anesthesia, and lung cancer.
From 2021 to 2023, Shandong Province will impose a total administrative fine of 218 million yuan and refuse to pay or recover 3.18 billion yuan from the medical insurance fund.
Compared with previous years, the medical insurance flight inspection involves a wider range of fields, more joint departments, and more intelligent supervision methods.
In terms of departmental linkage, from the initial joint operation with the National Health Commission and the Ministry of Public Security to carry out the special action to combat fraud and insurance fraud, to invite the Supreme People's Procuratorate and the Ministry of Finance to join the special rectification in 2023, and the Supreme People's Court to join in 2024.
Relying on the coordinated operations of various departments, administrative law enforcement and criminal justice have been effectively connected, clues on suspected corruption-related issues can be handed over more efficiently, and the role of medical insurance supervision as a "searchlight" for pharmaceutical anti-corruption has been continuously strengthened.
In terms of the areas investigated, according to the latest national flight inspection plan, this time it will focus on the fields of critical care medicine, anesthesia, lung tumors, etc., investigate and deal with the illegal use of medical insurance funds, and focus on investigating and dealing with fraud and insurance fraud. Focusing on cardiovascular medicine, orthopedics, blood purification and rehabilitation, medical imaging, clinical testing and other areas that have been focused on inspection and self-examination and self-correction in previous years, check whether they are self-examined and rectified as required.
In terms of big data screening, it is required to give full play to the role of verified and effective big data models to achieve normalized screening. Combined with the pilot work of medical insurance anti-fraud big data supervision and application, strengthen the application of drug traceability codes in the supervision of medical insurance funds, explore the construction of multi-dimensional big data models, screen and analyze suspicious clues in hidden data, and promote breakthroughs in big data supervision.
According to official disclosure, in 2023, 2.324 billion yuan will be refused through the in-process review. In 2023, more than 300 million yuan of medical insurance funds will be verified and recovered only through the verification of suspicious clues screened by the "false hospitalization" big data model.
Under the multi-means innovation, the efficiency of medical insurance supervision in 2024 has been greatly improved, and medical insurance supervision is entering a new dimension.
Source: Cyberblue Instruments