On October 16, the National Health Insurance Administration announced that seven hospitals in Huainan City, Anhui Province were suspected of using medical insurance funds in violation of laws and regulations.
1. Nantang Huimin Hospital, Shou County, Huainan City. First, it is suspected of inducing hospitalization and insurance fraud. The hospital signed an agreement with two nursing homes on the integration of medical care and elderly care, under which the nursing home will send patients to the hospital (accounting for 52.78% of the total number of hospitalizations during the examination period), and the hospital will transfer benefits (200 yuan/person) to the nursing home according to the capitation, and the patients will be transported by car and all personal expenses will be exempted. Second, it is suspected of fictitious diagnosis and treatment services and fraudulent use of doctors' signatures to defraud insurance. The hospital fraudulently issued a total of 3,433 imaging reports in the name of the physician Jiang, who had never actually worked in the hospital; During the absence of laboratory physician Ye Mousheng, other personnel fraudulently used Ye Mousheng's name to issue test reports and charge fees; Zhang Yuxiang of the radiology department fabricated a CT examination item and charged a fee without examining the patient. Third, it is suspected of falsely recording the number of diagnosis and treatment services to defraud insurance. In the CT examination of the hospital, some patients only checked one site, but charged more than two parts; Some have a fee but no inspection image record; Some of the diagnostic sites do not match the image description.
At present, the medical insurance department of Shou County has recovered all the funds used in violation of laws and regulations, dealt with 2 relevant medical personnel, terminated the medical insurance service agreement of the hospital, and initiated administrative punishment procedures for suspected fraud and insurance fraud. The health department has cancelled its practice license. A task force composed of public security, health and medical insurance departments has been stationed in the hospital to carry out further disposal.
2. Huainan Kangde Hospital. First, it is suspected of fraud in insurance without qualification to carry out inspection projects. The imaging department of the hospital carried out CT and DR examinations by unqualified personnel, and fraudulently used the signatures of qualified doctors to issue diagnostic reports, involving 2,700 people. Second, it is suspected of unqualified to carry out anesthesia project insurance fraud. There are no registered anesthesiologists in the hospital, and Qin Fucheng, an unqualified person, has carried out neuraxial anesthesia projects many times and charged fees, involving 186 people. Third, it is suspected of carrying out traditional Chinese medicine diagnosis and treatment services without qualifications and defrauding insurance. Wang Xilan, a physician at the hospital, did not have TCM qualifications, and carried out TCM diagnosis and treatment services such as acupuncture, acupuncture, and oral acupuncture in violation of regulations, involving 953 people.
At present, the medical insurance department of Panji District, Huainan City, has ordered the return of all illegal and illegal use of medical insurance funds, the termination of the hospital's medical insurance service agreement, and the initiation of administrative punishment procedures for suspected fraud and insurance fraud. At the same time, the relevant issues will be handed over to the public security, health and other departments for handling.
3. Huainan Shou County Renci Traditional Chinese Medicine Hospital. First, it is suspected of falsely recording the quantity of drug consumables and defrauding insurance. For example, ligustrazine phosphate for injection was actually used 1 vial each time, but 2 vials were declared and settled, involving 784 person-times; If the intraocular lens is not used, the intraocular lens fee is charged and the settlement is declared. Second, it is suspected of carrying out diagnosis and treatment services in violation of regulations and defrauding insurance. After the hospital added ophthalmology diagnosis and treatment subjects, it did not file with the medical insurance department in accordance with the medical insurance agreement, and the inspection found that the hospital had neither ophthalmic diagnosis and treatment equipment nor qualified ophthalmologists, but still carried out relevant services and collected fees. Third, it is suspected of excessive diagnosis and treatment and insurance fraud. Some patients in the hospital were hospitalized without indications, and some patients were diagnosed with lumbar disc herniation, but CT results showed no lumbar disc herniation.
At present, the Shou County medical insurance department has recovered all the illegal use of medical insurance funds, dealt with 1 relevant medical staff, terminated the hospital's medical insurance service agreement, and initiated administrative punishment procedures for suspected fraud and insurance fraud. The relevant departments of public security, health, market supervision and other relevant departments have received and handed over and have organized forces to carry out strict investigation and punishment in accordance with the law.
Fourth, Huainan City, Shou County, Zhengyangguan Town, Zhennan Community Health Service Station. First, it is suspected of fraudulent insurance by fictitious inspection items. Xia Mingyan, a laboratory doctor at the hospital, charged for fictitious test items by forging test reports when some patients did not undergo examinations. Second, it is suspected of excessive diagnosis and treatment and insurance fraud. Abuse of antibiotics in violation of diagnosis and treatment standards, the hospital uses two or three high-grade antibiotics for infected patients, regardless of the severity of their condition, such as cefazoloxime sodium, cefuroxime sodium, ornidazole, etc., and even the same antibiotics are prescribed orally and infusion at the same time.
At present, the medical insurance department of Shou County has recovered all the illegal use of medical insurance funds, dealt with 1 relevant medical staff, terminated the medical insurance service agreement of the hospital, and initiated administrative punishment procedures for suspected fraud and insurance fraud. The public security, health and other relevant departments have received and handed over and have organized forces to carry out investigation and punishment in accordance with the law.
5. Yimin Hospital of Shou County, Huainan City. After investigation, it was found that the hospital had the problem of medical insurance settlement of new projects without filing, and the hospital's "Medical Institution Professional License" added ophthalmology diagnosis and treatment subjects on February 6, 2023, and did not file with the medical insurance department in accordance with the requirements of the medical insurance agreement; There is a problem of duplicate charges, and the hospital collects "C-reactive protein determination" and separately charges "hypersensitive C-reactive protein assay".
At present, the Shou County Medical Insurance Department has ordered the return of all illegal and illegal use of medical insurance funds, the treatment of 2 relevant medical personnel, the termination of the hospital's medical insurance service agreement, and the transfer of other problems to the market supervision and other departments for investigation and punishment.
6. Huainan Shou County Harmony Hospital. After investigation, it was found that the hospital had problems of excessive inspection, excessive medication and other violations of laws and regulations. For example, the hospital has carried out a large number of "pathological gross specimen photography" examinations that are not clinically significant.
At present, the Shou County Medical Insurance Department has ordered the return of all illegal and illegal use of medical insurance funds, the handling of 2 relevant medical personnel, the suspension of the hospital's inpatient medical insurance service agreement, and the transfer of other problems to the health and other departments for strict punishment.
7. Huainan Shouzhou Elderly Apartment Rehabilitation Hospital. After investigation, it was found that the hospital had violations of laws and regulations such as exceeding the scope of diagnosis and treatment services and excessive inspections. If there is no indication, the eight items of immunization, a complete set of rheumatism, myocardial triplet, left heart function measurement and other examination items should be carried out.
At present, the Shou County Medical Insurance Department has recovered all the illegal use of medical insurance funds, suspended the hospital's inpatient medical insurance service agreement, and handed over the relevant clues to the health department for strict punishment.
At present, the follow-up handling of the above-mentioned cases is being further promoted, and the public security, health, market supervision and other departments have launched investigations. At the same time, the medical insurance department of Huainan City, Anhui Province drew inferences from one case to another, carried out special inspections on designated medical institutions at all levels in the city, and promoted the city's designated medical institutions to take the initiative to standardize the use of medical insurance funds, and resolutely did not touch the "high-voltage line" of medical insurance supervision.
■Source: Official website of the National Health Insurance Administration
■Editor: Yue Yue, Zhang Grandma