What is an indicated, low-indication admission? What conditions can't be admitted to the hospital? Explain it in one article

Low-standard hospitalization refers to patients with unclear indications for admission, who can be treated on an outpatient basis, or who undergo physical examination-style examinations during hospitalization but do not receive substantial treatment.

What is considered an asymptomatic or low indication admission?

(1) Designated medical establishments violate the "Clinical Diagnosis and Treatment Guidelines", the hospitalization standards formulated by the health department, and admit patients who have no indication for admission and can be treated in an outpatient setting. Include:

• Those whose condition is simple and clear, and who are mainly treated with oral drugs and admitted to the hospital, such as chronic gastritis, pelvic inflammatory disease, etc.;
• Fatty liver and hyperlipidemia without symptoms and complications;
• Common diseases and surgeries in outpatient clinics can be observed and treated in outpatient clinics or outpatient clinics but are hospitalized, such as small body surface masses, postoperative extubation (except for the urinary system requiring laparoscopic operation), oral outpatient treatment, etc.

(2) If the patient only undergoes various examinations, examinations and simple treatment during the hospitalization, the main purpose is to have a health examination.

(3) Patients with tumors or strokes who are in stable condition are mainly treated with oral medication after being admitted to the hospital.

(4) Excessively exaggerating the harmfulness of the disease to the patient, or inducing the patient to be hospitalized for treatment on the grounds that hospitalization can be reimbursed.

(5) Mobilize the masses to be admitted to the hospital for physical examination through free clinic activities, and include the cost of the physical examination in the medical insurance payment until there is no indication for admission on the day of the examination.

(6) Other circumstances that are found to be lowering the standard for hospitalization.

If one of the above conditions is met, it will be regarded as admission without indication or low indication, and will be handled in accordance with the medical insurance service agreement and relevant provisions of fund supervision.

The following conditions are considered mild and should not be hospitalized.

Minor injuries (no complications)

1. Small area abrasions, such as abrasions with an area of < 5cm²;

2. Small hematoma, such as hematoma< 10ml; However, the skull and face are excluded

3. Mild soft tissue contusion, except for thoracic and abdominal organ injury;

4. 1st degree and mild second-degree or small burns;

5. Sprains, such as foot sprains, lumbar sprains, etc., which exclude fractures and tendon injuries

Minor surgery

Lumps on the body surface that can be treated on an outpatient basis, such as small simple lipomas, small fibromas, and sebaceous cysts.

Skin diseases

Complications of general dermatitis, skin boils, atopic dermatitis, neurodermatitis, scabies, etc.

Respiratory diseases

Acute upper respiratory tract infection without complications or comorbidities (except infants and young children), chronic bronchitis in remission.

Digestive disorders

Chronic gastritis, mild Helicobacter pylori infection, general diarrhea, chronic colitis, chronic proctitis, acute gastroenteritis without electrolytes and pH imbalance, chronic fatty liver, alcoholic liver, etc. However, if the patient's condition does not improve after outpatient standard treatment, the patient can be admitted to the hospital according to the patient's condition.

Proctology diseases

Internal and external hemorrhoids or anal fissures that do not require surgical treatment, but if there is co-infection and bleeding, moderate or above anemia; or thrombotic external hemorrhoids, patients with incarcerated hemorrhoids; or patients with severe anal pain.

ENT diseases

Rhinitis, sinusitis, chronic pharyngitis, conjunctivitis, otitis externa, otitis media without surgical treatment; Simple oral infection, periodontitis, caries, meibomian gland cyst, etc. without comorbidities and complications.

Genitourinary diseases

General urethritis, vaginitis (except for acute purulent vaginitis), trichomoniasis or fungal vaginitis, chronic pelvic disease (except for acute attacks), general chronic cervicitis (except for those with a large amount of subband, contact bleeding, which seriously affects the quality of life and requires cervical radiofrequency ablation), pregnancy reaction (electrolyte imbalance caused by hyperemesis, positive urine ketones, vomiting after ingestion, and inability to take food and water by mouth), long foreskin (except for those under 14 years of age), Non-recurrent urinary tract infections (except for patients with systemic infections), prostatic hyperplasia (except for moderate and severe and those requiring surgery), kidney stones (except for renal colic and those requiring surgery and extracorporeal lithotripsy)

Diseases of the locomotor system

General low back pain, hyperostosis, cervical and lumbar disc herniation, cervical spondylosis (except for nerve and vascular compression and functional dysfunction, and indications for surgery); Frozen shoulder (no improvement after 1 week of outpatient treatment, or obvious pain in the acute phase, except for those that affect daily life), rheumatoid arthritis (no functional impairment), tenosynovitis (except for those requiring surgical treatment).

Other systemic diseases

1. Stable phase of malignant tumor without intensive supportive care and chemotherapy;

2. Facial paralysis, chronic migraine, and chronic trigeminal neuralgia without comorbidities

3. Cerebral arteriosclerosis, hyperlipidemia, hypertension, etc. without complications or comorbidities.

Medical insurance flight inspection logic

Logic 1: Focus on monitoring cases with a short hospital stay, and judge the reasonableness of admission based on medical treatment and disease course records.

Example: Fu Mouzhen, an inpatient, was admitted to the hospital on May 27, 2023, and discharged on May 28, 2023, and was diagnosed with "lumbar vertebra bone hyperplasia" after being discharged from the hospital, and was actually hospitalized for 1 day, which did not meet the indications for admission, and the amount of medical insurance reimbursement was 157.24 yuan during the hospitalization.

Logic 2: Bed hanging hospitalization and low-standard admission are usually linked, which can be further identified by surprise night inspection.

Example: The medical insurance department organized a special night inspection action of "lowering the admission standard", and found that the three insured persons in the hospital were not in bed, and through reviewing the medical records, it was found that the medical orders of the above three insured persons during their hospitalization only issued examination items, and there was no need to be hospitalized, and there was a violation of lowering the hospitalization standard to admit the insured patients. After deducting the violation fee of 1162.8 yuan, 2 doctors were dealt with.

Logic 3: Take patients with multiple health examination items as the key monitoring, and conduct random checks on the course of medical records.

Example: Wang, an inpatient with admission diagnosis: genital warts of the vulva. There were no diagnosis-related examinations or treatments in the medical records, but it was found that the medical records contained abdominal ultrasound, liver function, blood glucose, electrocardiogram and other examination reports. Suspected of low-standard hospital admission for the purpose of a health check-up.

Logic 4: Screening for diseases and surgeries that are obviously common in outpatient clinics should be screened in the inpatient data.

Example: Xu, an inpatient with an admission diagnosis: periodontitis. The actual hospitalization was 3 days, and the medical records recorded the course of the disease, such as scaling, scaling, and root surface leveling, and the above treatment should be carried out on an outpatient basis, which is a reduction in the standard of admission.

Logic 5: The induced low-standard admissions usually have group characteristics, for example, the daily admission number of a private hospital is relatively average, but the number of admissions in a certain day is increased by big data analysis, which can be further reviewed.

Example: After verification, it was found that from January 2023 to December 2023, a hospital induced insured persons to be hospitalized by means of "no money for eating, no deposit for hospitalization", etc., and there were violations such as insufficient diagnostic basis and lowering admission standards, involving illegal expenses of 99,358.35 yuan.

Source: Yueqiang Culture, Guigang Medical Security Bureau, Run Bar Medical Insurance People (reprinted for sharing only, the copyright belongs to the original author.) If there is an error or infringement of the source, please contact us, we will correct and delete it in time, thank you! ）

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