The medical security fund is the people's "medical money" and "life-saving money", but there are frequent cases of waste or reselling drugs to obtain the medical insurance fund due to excessive drug purchases, which seriously threatens the safety of the fund.
01 3 months to buy 15 years of medication
Yulin cracked the "reflux drug" case
A few days ago, the Yulin Medical Insurance Bureau of Shaanxi Province found abnormal drug purchases in the verification process, and the insured purchased 15 years of treatment drugs within 3 months.
The staff of the Yulin Medical Insurance Bureau found in the daily inspection that the insured Chang had a chronic disease and needed to be treated with medication all year round, but through data analysis and comparison, it was found that Chang purchased drugs with high frequency and quantity, which was inconsistent with the routine.
The Yulin police's investigation of Chang found that Chang suffered from chronic renal failure and other diseases, and according to the chronic disease medical insurance reimbursement policy, Chang's usual medication medical insurance reimbursement reached 85%. Chang saw an opportunity to resell some of the extra drugs to drug dealers at low prices, and the drug dealers then flowed the drugs to the market. Through the investigation of the inspectors of the Medical Insurance Bureau and the police, it was found that cases like Chang's are not unique.
Hao Xingle, Squadron Leader of the Fourth Criminal Police Squadron of the Yuyang Branch of the Yulin City Public Security Bureau: We are investigating and investigating several cases of medical insurance fraud, and we have found that some people have obtained drugs through over-dispensing and repeated dispensing, and then resold them to drug dealers, directly selling and indirectly assisting in the sale of "reflux drugs", resulting in the people's life-saving medical insurance funds being eaten by lawbreakers.
Liu Xiaoyi, deputy director of the Yulin Municipal Medical Security Bureau: Drug dealers induce patients to prescribe drugs more frequently and in multiple locations on the grounds that they can make money by reselling medical insurance drugs, and then recycle them. When the drug reaches a certain amount, the drug is sold to some illegal operators, or sold at a low price through the Internet.
02 Establish a "traceability code" payment supervision system
In order to put an end to the phenomenon of repeated over-prescribing of drugs between different hospitals, the National Health Insurance Administration promotes the sharing of drug medical insurance settlement information between different medical institutions, realizes the extension of post-supervision to pre-warning, and eliminates "over-purchase of drugs" from the source.
At present, the National Health Insurance Administration is carrying out a big data supervision pilot, and Yulin, Shaanxi Province, as a pilot city, promotes the application of the "traceability code" of medical insurance drugs in outpatient co-ordination and designated pharmacies, realizing the integration of the traceability code and the commodity code, and forcing the code to be scanned in the drug settlement and medical insurance payment links. Fully grasp the information of the prescribing institution, the number of drugs purchased, and the purchase cycle. The pharmacy sales staff told reporters that the system will automatically remind the insured to buy drugs in advance or in excess of any pharmacy in Yulin City.
In terms of preventing secondary sales, according to the principle of "one drug and one code, there is a code to be verified" of the traceability code, the system will also give real-time alarms if it is found that the duplicate "traceability code" and secondary sales are found. As of June 10, in 81 chronic disease pharmacies in Yulin City, the "traceability code" control system compared a total of 2.03 million pieces of data, intercepted the same drug and paid again 14,057 times, involving a cost of 1.2629 million yuan.
The reporter learned that the National Health Insurance Administration is actively exploring the development of the "reselling medical insurance drugs" big data supervision model, improving the intelligent reminder function of the medical insurance intelligent monitoring system, and putting an end to the phenomenon of repeated drug prescribing between different hospitals and reselling more drugs for profit.
Yang Ling, Director of the Second Supervision Division of the Fund Supervision Department of the National Medical Security Administration: At present, nearly half of the provinces in the country have started the work of reminding abnormal drug prescriptions, of which Beijing, Tianjin, and Ningxia have basically achieved full coverage; Zhejiang, Hainan, Xinjiang, Inner Mongolia and other countries are also advancing, and will also be deployed at the national level in the future.
03 "Reflux drugs" disrupt the market order
It is difficult to ensure the safety of medication
The existence of "reflux drugs" has seriously disrupted the order of the normal drug market, and through the "black hands" of drug dealers, "good medicines" may become "poisons", and it will be difficult to ensure the safety of drug use.
The reporter found a lot of small advertisements for the purchase of drugs on the Internet and around some hospitals. The reporter noticed that the "reflux drugs" purchased by drug dealers include a large number of high-priced anti-cancer drugs and targeted drugs. At the same time, the reporter learned from the National Health Insurance Administration that judging from the recent investigation and handling of cases, there are also drug dealers who extend their tentacles to drugs that require special storage.
Yang Ling, Director of the Second Supervision Division of the Fund Supervision Department of the National Health Security Administration: For example, insulin, capsules of live bifidobacteria, etc., these drugs require specific storage, and if they cannot meet the conditions for such storage, their quality and effect will be affected.
However, out of the normal drug circulation supervision link, the risk of "reflux drugs" is far more than that.
Yang Ling, Director of the Second Supervision Division of the Fund Supervision Department of the National Health Security Administration: Some drug dealers sell real drugs to such small clinics with scattered medicines, and then fill the real medicine boxes with fake drugs and sell them to pharmacies, so as to confuse the real with the fake. The second is that many drug dealers remove nearby or expired drugs from their original packets and put them in new boxes. The patient only sees the new date on the pill box and does not know that he is taking the expired medicine. In the process of dismantling and reassembling "reflux drugs", some drug dealers are often confused about its dosage specifications and types of drugs, for example, children eat adult doses, etc., which not only affects the efficacy, but may also endanger health and life.
04 Directly or indirectly assisted in the sale of "reflux drugs"
All of them are involved in fraud and insurance fraud
According to the National Health Insurance Administration, direct sales or indirect auxiliary sales of "reflux drugs" are suspected of fraud and insurance fraud. The National Health Insurance Administration reminds that the insured should be vigilant, do not buy drugs from unknown sources and damaged packaging, and do not turn the "life-saving drugs" in their hands into "cash cows" for drug dealers.
According to the "Guiding Opinions on Several Issues Concerning the Handling of Criminal Cases of Medical Insurance Fraud" jointly issued by the Supreme People's Court, the Supreme People's Procuratorate, and the Ministry of Public Security in February 2024, those who illegally purchase or sell drugs that they know are purchased through medical insurance fraud shall be convicted and punished for the crime of covering up or concealing criminal proceeds; Instigating, instigating, or instigating others to use medical insurance to fraudulently purchase drugs, and then illegally purchase or sell them, is to be convicted and punished as the crime of fraud.
At the same time, for the insured, the resale of drugs may face the penalty of not being able to use medical insurance, and even constitute the crime of fraud.
05 In case of "reflux drugs", you can report to the medical insurance department
A few days ago, the National Health Insurance Administration, the Supreme People's Court, the Ministry of Public Security, the National Health Commission and other six departments jointly deployed the special rectification of violations of laws and regulations in the medical insurance fund.
If you find similar fraud and insurance fraud, you can call the National Health Insurance Bureau's anti-fraud and insurance fraud reporting hotline in time, or report to the local medical insurance department, and the medical insurance department will give a reward of up to 200,000 yuan depending on the report.
Source: CCTV News