The staff of the Discipline Inspection Commission of Huai'an District of Huai'an City discussed the clues of key issues in the field of medical insurance funds. Photo by Zhang Yun
In response to these problems, the Discipline Inspection Commission of Huai'an City, Jiangsu Province, has adopted methods such as project supervision and special supervision to build four mechanisms of key information notification, joint inspection, transfer of clues, and joint punishment, severely punish the corrupt behavior behind fraud and insurance fraud, and effectively safeguard the vital interests of the masses.
In view of the frequent occurrence of violations in medical institutions, increase the intensity of punishment and form a continuous deterrent
"The Xisongji Health Center in Huaiyin District violated regulations to lower the standards for admission and admission of patients, suspected of defrauding medical insurance expenses, gave the former president Jiang Qikun (later the president of the Guzhai Health Center) a serious warning within the party, a punishment for excessive administrative records, and removed him from the post of president of the Guzhai Health Center..." Recently, the Discipline Inspection Commission of Huai'an City discipline inspection commission successively reported on the investigation and handling of many typical cases of public employees participating in fraud and insurance fraud in Huaiyin District, Huai'an District, Lianshui County, Qingjiangpu District and other places, involving an amount of 2.277 million yuan.
"These case clues are all transferred by the Medical Insurance Bureau, we conducted an in-depth investigation according to the clues, and found that the Xisongji Health Center has admitted 8 elderly people with five guarantees into the hospital, and the same disease has been repeatedly admitted to and from the hospital within 15 days, decomposed hospitalization, and even individual patients have been admitted and admitted to the hospital repeatedly for 45 times in 2 years, which obviously exceeds the scope of reasonable and necessary medical services, and is suspected of defrauding medical insurance costs of more than 700,000 yuan." According to the case-handling personnel of the Discipline Inspection Commission of Huaiyin District, the investigation found that some grass-roots medical institutions used fraudulent insurance methods such as lowering the admission standard and decomposing admission. For example, the Yixing Town Health Center in Lianshui County destroyed, destroyed, and tampered with medical records by tearing up the inspection date, tampering with the inspection results, scratching the diagnostic opinions, digging up the inspection sample number, deliberately folding the inspection form and sticking it with glue, etc., so as to achieve the purpose of illegally withdrawing medical insurance funds.
In this regard, the Huai'an Municipal Commission for Discipline Inspection supervision and supervision of fraud and insurance fraud has promoted special governance in the field of medical insurance funds. On the one hand, it firmly grasps the leading department of the Medical Insurance Bureau, urges it to earnestly shoulder the main responsibility for business supervision, seriously investigates and deals with the problem of medical institutions cheating insurance, and promptly transfers clues to the discipline inspection and supervision organs at the same level that involve party members and cadres and the objects of supervision. On the other hand, an all-round supervision network is established under the overall coordination of the supervision departments, the precise embedding of discipline inspection and supervision teams stationed there, the direct investigation and expedited investigation and expedited office of the county and district discipline inspection commissions, and the close cooperation of discipline inspection and supervision institutions within each public medical institution, so that cases with strong reactions from the masses and complicated circumstances are listed for supervision, and difficult cases are jointly handled by cities and counties.
Since the beginning of this year, the Supervision Commission of the Huai'an Municipal Commission for Discipline Inspection has successively listed and supervised 5 key cases. Among them, in response to the problem of fraud and insurance fraud in the hand and foot microsurgery diagnosis and treatment team of Huai'an Hospital and Chuzhou Hospital of Traditional Chinese Medicine assigned by the National Medical Security Bureau, the Supervision and Inspection Office of the Municipal Commission for Discipline Inspection and Supervision, together with the Supervision and Supervision Commission of the County and District Discipline Inspection Commission, intervened in advance and organized several rounds of meetings and chambers of commerce around the characterization of violations and the identification of personnel qualifications, and finally, 22 public employees were held accountable and held accountable, and more than 1.5 million yuan of illegal funds were recovered.
"Since the beginning of this year, the discipline inspection and supervision organs at all levels in the city have investigated and handled 28 cases of violations of discipline and law in the field of medical insurance, punished 31 people for party discipline and government affairs, and urged the regulatory departments to deal with 1152 illegal medical institutions, involving 79.309 million yuan of illegal funds." A relevant responsible person of the Huai'an Municipal Commission for Discipline Inspection said.
Aiming at the weak links that are prone to rent-seeking - combining online and offline, strengthen daily supervision
"In February this year, the Boli Health Center issued 12 warnings in the same month, and asked your bureau and the health department to immediately find out the reason." Not long ago, the Discipline Inspection Commission of Huai'an District of Huai'an City found problems through online supervision and urged the regulatory authorities to perform their main responsibilities for the first time.
"After investigation, the health center has violations such as over-range diagnosis and treatment, hanging bed hospitalization and so on." Due to the minor circumstances, our bureau has notified the health department to interview the president of the hospital and deduct the illegal fees. Three days later, the Huai'an District Medical Insurance Bureau submitted the results to the District Discipline Inspection Commission.
Previously, the Supervision Commission of the Huai'an Municipal Commission for Discipline Inspection found in the process of supervising the field of medical security funds that the daily supervision of the Huai'an Medical Insurance Fund is still mainly based on manual spot checks, which is not only inefficient in supervision, but also very easy to generate space for rent-seeking. To this end, the Huai'an Municipal Commission for Discipline Inspection supervision commission to special supervision as the starting point, in-depth public medical institutions to visit and investigate, and gradually find out the relevant processes and key links of diagnosis and treatment services and medical insurance reimbursement, supervise the medical insurance bureau to establish a disease diagnosis and treatment model according to 2501 diseases in Huai'an City, screen out key indicators such as hospitalization costs, length of hospitalization, project violations, suspiciousness of suspicious points, etc. To set early warning scores, and embed the "Supervision of the Discipline Inspection Commission Supervision Commission" module in the municipal medical insurance supervision platform, and carry out online automatic early warning at different levels. The second-level early warning is pushed to the medical insurance department for verification, and the third-level early warning is pushed to the Discipline Inspection Commission Supervision Commission to track and supervise and further verify whether there are any violations of discipline and law.
The setting of hierarchical early warnings allows every medical suspected problem clue in the city to be exposed to the "sunshine", the details of all problem clues, the progress of processing are all displayed online, the whole process is traced, the results are made public, the medical insurance problem clues are not checked, how to check, and the Discipline Inspection Commission Supervision Commission can trace online at any time and check the responsibility.
In addition to online normalization supervision, the Huai'an Municipal Commission for Discipline Inspection and Supervision selects a work focus every quarter to carry out special supervision, and in the first three quarters of this year, special supervision is carried out around the innovation and promotion of medical insurance fund supervision methods, the collection of illegal funds, and the follow-up and disposal of early warning problems, and more than 40 problems are handed over on the spot.
"In the past, the law enforcement and supervision discretion of the medical insurance system was relatively large, and with the continuous strengthening of the supervision of the Discipline Inspection Commission, we were forced to investigate violations of laws and regulations to the end, and also put forward higher requirements for the work efficiency and integrity of the medical insurance fund supervision team itself." Yin Yaqin, director of the Huai'an Municipal Medical Insurance Bureau, said.
In view of the problem of poor information exchange between departments, promote the construction of a joint management office and a long-term supervision mechanism
"The party committee of the Health commission emphasizes performance over management, the salary performance bonus of the grass-roots health center basically refers to the income of the diagnosis and treatment business, the education and management mechanism for the responsible persons of the grass-roots health centers and their medical technicians is missing, the education of medical ethics and medical style is not attached, the assessment and management of the insured personnel in the hospitalization management is not strict, and there are loopholes in the internal control mechanism."
The Discipline Inspection Commission of Lianshui County, Huai'an City, recently issued a disciplinary inspection recommendation to the county Health Commission. In view of the frequent occurrence of illegal insurance fraud in grass-roots health centers, excessive medical treatment, and induced hospitalization found in the process of supervision, the county health commission is required to effectively shoulder the main responsibility of supervision, improve relevant institutional mechanisms, and put an end to such problems.
"We have seized the opportunity of the national medical insurance fund supervision method innovation pilot to promote departmental linkage supervision, third-party joint investigation and supervision, and coordinated supervision by the Discipline Inspection Commission, forming a 'joint management and joint office' model for medical insurance fund supervision." According to the relevant responsible person of the Huai'an Municipal Commission for Discipline Inspection and Supervision, the city regularly holds joint meetings on medical insurance work attended by discipline inspection and supervision, medical insurance, health care, public security, and market supervision departments, and has established four working mechanisms, such as briefing on key situations, joint inspection, transfer of clues, and joint disciplinary action.
At the same time, the Supervision Commission of the Huai'an Municipal Commission for Discipline Inspection paid attention to solving "big problems" through "small incisions", centered on the problem of fraud and fraud in grass-roots health centers found in the process of supervision, and carried out in-depth research with the Municipal Health Commission and the Municipal Medical Insurance Bureau, successively visited 14 grass-roots health centers, interviewed 63 people, excavated the deep-seated reasons such as insufficient fund payment, imperfect feedback and appeal mechanism, obvious emphasis on punishment, and serious loss of backbone talents, and formed a special research report to report to the main leaders of the municipal party committee. Promote the transformation of physical supervision into effective supervision. At the same time, dig deep into the root causes behind the problems, identify the blockages and difficulties, study and formulate the "Implementation Plan on Supervising and Promoting the Supervision of the City's Medical Insurance Fund", and clearly focus on the four key contents of the medical insurance system reform, industry style construction, key work promotion, and typical problem investigation and handling for normal supervision, and promote the formation of a long-term supervision mechanism.
"While pursuing responsibility and accountability for those who violate discipline and law, we can deeply find the root cause behind the problem, and promote relevant units to make up for the shortcomings of the system and plug regulatory loopholes, so as to continuously consolidate the results of special supervision in the field of people's livelihood and medical treatment." Ye Bei, deputy secretary of the Huai'an Municipal Discipline Inspection Commission and deputy director of the Municipal Supervision Commission, said that the next step will be to formulate and issue proposals to units and regions with high incidence of problems, effectively give play to the functions of correcting errors, disposing of, and curing the root causes of discipline inspection and supervision suggestions, and promote the "big article" of the long-term mechanism with special supervision. (Li Ying, Zhang Jin)