Previously, in the "2022 Medical Security Fund Unannounced Inspection Work Plan" issued by the National Health Insurance Administration, it was clearly pointed out that the time frame of the inspection is the use of the medical insurance fund since January 1, 2020, that is, the use of the medical insurance fund of the two medical institutions in the past two and a half years can be traced back to the illegal and illegal use of the medical insurance fund of the two medical institutions. According to the "work plan", each group of unannounced inspections lasts for about 10 days, and will focus on the use of hemodialysis treatment and high-value medical consumables (orthopedics, cardiology) in medical institutions that are included in the scope of payment by the medical insurance fund.
This article will bring you the key points of medical insurance flight inspection of high-value medical consumables (orthopedics, cardiology), as well as the analysis of related violation cases.
Common risk points of medical consumables in medical insurance flight inspection
1
Medical consumables are sold at zero price difference
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". In the process of selling with zero price difference, it is inevitable that there will be objective or subjective mistakes, such as:
(1) For the same kind of consumables, due to the change of production process or the increase or decrease of cost, the price of two batches of different batches of products is different, and the medical institution does not adjust the charging items in time;
(2) Sold at the price of the provincial platform without purchasing on the provincial platform, that is, offline procurement as we say;
(3) The consumables given by the purchased equipment are charged according to the provincial platform price without purchase data.
2
Serial swapping and serial coding, sleeve labeling
(1) Cascade exchange: mainly to replace the consumables without charging basis with consumables with charging basis;
(2) Serial code: replace the consumables in the non-medical insurance catalogue with the consumables in the medical insurance catalogue for charging;
(3) Set of standards: Replace consumables with low purchase price (sales price) for consumables with high purchase price (sales price) for charging and reimbursement.
At present, medical consumables have their own 27-digit standard code, and with the update of product regulations, medical institutions do not replace the new standard code in time will also lead to the serial code charge of medical consumables, and the medical insurance will take the registration certificate corresponding to the standard code of medical consumables and check the registration certificate on the physical part of the medical institution to see if it is consistent.
3
The purchase, sale and inventory data is abnormal
The purchase, sale and inventory of medical consumables is a must-check item for medical insurance flight inspection, and whether there are false or overbilled consumables can be determined through the retrieval of purchase, sale and inventory. Because the opening inventory of medical consumables plus the warehousing quantity minus the ending inventory, this value must be greater than or equal to the number of charges, once the number of charges increases abnormally, it indicates that this kind of consumables must be more false or billed.
Key points of medical high-value consumables
(1) Whether the medical consumables are not recorded or kept in the same account and warehousing list with the goods;
(2) Whether there is a storage of medical consumables, and there is no purchase invoice and accompanying list;
(3) Compare the purchase, sale and inventory data with the uploaded data of medical insurance, and whether there is any collusion of items or false uploads;
(4) Addition of medical consumables.
Medicines, consumables, instrument use, etc
Be sure to pay attention to the five logics
(1) Inventory at the beginning of the period + warehousing during the period - inventory at the end of the period = the actual outbound ≥ quantity ≥ during the period; (Medicines, Consumables, Reagents)
(2) Inventory at the beginning and end of the period: drug depot account = financial account
(3) The quantity and amount of warehousing during the period: drug warehouse account = financial account (sequence account)
(4) Instrument: the maximum usable amount > the number of chargeable items
(5) (Income + Assets + Receivables) - (Expenses + Payables) <0
Orthopedic consumables focus on investigation
(1) Serial exchange of high-value medical consumables. Designated medical institutions defrauded the medical insurance fund by replacing high-value medical consumables for orthopedics.
(2) Falsely record the number of medical consumables. Designated medical institutions defrauded the medical insurance fund by falsely recording high-value medical consumables for orthopedics.
(3) Forging or providing false supporting materials. Designated medical institutions defraud the medical insurance fund by forging or providing false supporting materials.
(4) Focus on screening orthopedic consumables. Meniscus suture system, pad, spacer, nail board, nail plate system, nail rod, nail rod fixation system, revision femoral stem, femoral stem, femoral head, bone wax, bone traction needle, bone cement, bone cement handle, fixing nail, posterior fixation system, spinal fixation system, shoulder joint system, bone plate, bone plate screw, bone plate system, bone plate screw, anatomical bone plate, metal bone needle, metal bone plate, cervical spine fixation system, absorbable snail, absorbable bone meal, absorbable screw, hip femoral stem, hip joint system, acetabular cup, Acetabular lining, acetabular system, lining, internal fixator, internal fixation system, artificial joint, fusion device, intramedullary nail, locking bone plate, titanium plate, ceramic ball joint, allogeneic bone, external fixation brace, absorbent bone grafting material, knee prosthesis, knee joint system, elbow joint prosthesis, lamina fixation system, anti-adhesion gel, silicone gel, collagen sponge, absorbable hemostatic gel, biological glue, hydrogel dressing, medical glue, hemostatic sponge.
Key points of cardiology consumables examination
During the inspection period, the procurement, management, use and payment of high-value consumables used by the cardiovascular department of designated medical institutions and its related professional departments (including but not limited to interventional departments, catheterization laboratories and DSA rooms) shall be inspected in accordance with the relevant policies of medical insurance, focusing on the charges, payment and "purchase, sale and inventory". If necessary, expand the scope of examination to include common low-value consumables related to cardiology.
Relevant knowledge, basis and regulations
1. Regulations on the Supervision and Administration of the Use of Medical Security Funds (Order No. 735 of the State Council)
2. Interim Measures for the Administration of Designated Medical Security in Medical Institutions (Decree No. 2 of the National Medical Security Administration)
3. Regulations on the Supervision and Administration of Medical Devices (Order No. 276 of the State Council)
4. Administrative Measures for the Clinical Use of Medical Devices (Decree No. 8 of the National Health Commission)
5. Notice of the General Office of the State Council on Printing and Distributing the Reform Plan for the Governance of High-value Medical Consumables (Guo Ban Fa [2019] No. 37)
6. Measures for the Management of Medical Consumables in Medical Institutions (Trial) (Guowei Yifa [2019] No. 43)
7. Clinical Technical Practice Specifications - Cardiovascular Diseases (Chinese Medical Association)
8. Clinical Technical Operation Specifications - Orthopaedics (Chinese Medical Association)
9. "Interventional Diagnosis and Treatment Technology Management Standards for Cardiovascular Diseases" (Wei Yi Fa [2007] No. 222)
10. "National Medical Service Price Project Specification (2012 Edition)"
11. Medical insurance medical consumables classification and code database
12. Specifications for medical service price items and consumables management catalogue in the inspected area
Analysis of violation cases
Case 1
When "percutaneous intracoronary stenting" is performed, both "percutaneous intracoronary stenting" and "percutaneous endoluminal coronary angioplasty" are charged
Problem qualitative: Duplicate charges
Description: According to the regulations of the medical service project, "all kinds of stenting include dilation"
Case 2
To carry out transvascular interventional treatment, local infiltration anesthesia, puncture, injection, catheterization and other fees will be charged separately
Problem qualitative: Duplicate charges
Note: According to the provisions of the medical service project, "transvascular interventional diagnosis and treatment" includes local infiltration anesthesia, puncture, injection, and catheterization
Case 3
In the process of using surgical consumables, the director of orthopedics and the director of neurosurgery of a hospital implanted low-value orthopedic screws (1,200 yuan/piece) instead of high-value minimally invasive nails (3,600 yuan/piece) into the patient's body.
Problem qualitative: collusion charges
Case 4
The orthopedic department of a hospital has 3 departments, equipped with 3 red light therapy instruments and 24 infrared therapy instruments. Through on-site inspection, investigators found that the red light and infrared therapy devices were used normally in the orthopedic ward. The list of orthopedic inpatients and some patients' medical records in the hospital in the past three years were retrieved, and it was found that the doctor's orders were all "red light therapy", and none of them were "infrared therapy".
Problem qualitative: collusion charges
Source | Medical Power Medical Management Center
Edit | Liu Ying, Gao Pengfei
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