Treatment and reform of medical disorder

On the evening of June 1, the party group of the Nan'an District Medical Insurance Bureau of Chongqing City and the Discipline Inspection and Supervision Group of the District Discipline Inspection Commission Supervision Committee in the District Health and Health Commission took a no-hello, direct-to-site, and unannounced inspection to launch the Chongqing People's Hospital at night Inspection, focusing on whether there are empty bed hospitalization, hanging bed hospitalization, impersonation hospitalization and other behaviors. (Photo courtesy of Nanan District Commission for Discipline Inspection)

In the process of prescribing medicine, if there is a symptom of the medicine, the dosage of the medicine exceeds the general range, etc., the medical insurance intelligent monitoring and auditing system will pop up a window to remind the situation. The picture shows the operation of the system of physicians in the outpatient clinic of integrated traditional Chinese and western medicine in Nanan District Hospital. (Photo courtesy of Nan'an District Medical Insurance Bureau)

  Recently, the intelligent monitoring and auditing system for medical insurance in Nan'an District of Chongqing City has started trial operation in two medical institutions in the district. It is understood that as the system rolls out data networking in medical institutions in Nan'an District, the district medical insurance bureau can monitor the operation of the fund in real time, and doctors can also clearly understand patient records online to avoid repeated prescribing and excessive prescribing, which has increased fraud The efficiency of fraud detection.

  The medical insurance intelligent monitoring and auditing system was put into use in the Nan'an District, which originated from the profound reflection on the case of the academic hospital in the district defrauding more than 10 million yuan of medical insurance funds. The relevant person in charge of the Nan'an District Commission for Discipline Inspection and Supervision Commission said: "This system can automatically review all data of medical institutions on the Internet, and can also open data channels with the Nan'an District Health and Health Commission to share relevant data and explore the linkage of medical, medical insurance, and medicine ."

  A whistleblower letter brings out 10 million medical insurance fraud cases

  In January 2018, Chongqing Nan'an District Commission for Discipline Inspection received a report from the masses, reflecting that the then district human resources and social security bureau party committee member and district social insurance bureau Wen Ying accepted bribes from the academic hospital and increased medical insurance coverage for the academic hospital.

  Earlier, the public security organs of Chongqing Municipality had filed a case for suspected fraud against Zhang Mou, the former dean of the Xuefu Hospital, legal representative, and actual controller Liang Mou. At this time, a mass report was received reflecting the cadre-related issues, which attracted the attention of the Nan'an District Discipline Inspection Commission. A preliminary investigation found that Wen Ying’s salary was rarely used, but there was a record of large luxury consumption.

  Comprehensive understanding of the relevant situation, the investigation team believes that Wen Ying is suspected of violating discipline and law. In July 2018, the Nan'an District Commission for Discipline Inspection Commission followed the procedures for approval by the Municipal Commission for Discipline Inspection Commission and took lien measures against Wen Ying.

  "After being detained, Wen Ying panicked." According to the case handler, Wen Ying said nothing at the beginning of the conversation. "She is an old party member who has been educated by the party for many years. On the one hand, we asked the case to do investigation work, and at the same time let her learn the party constitution. She also took out her application for joining the party to let her revisit her original intention when joining the party and do a good job. Political work."

  At the same time that Wen Ying was retained, the Nan'an District Supervision Committee received a clue from the district public security branch about the bribery of the academic hospital to the relevant staff of the original health planning committee and medical insurance center in Nan'an District. The preliminary verification confirmed Zhang and Liang. Suspected of bribery. With the approval of the Municipal Supervision Committee, the Nan'an District Supervision Committee investigated Zhang and Liang, and took detention measures according to law.

  The evidence obtained from the peripheral investigations was successively placed in front of Wen Ying, and the ideological and political work also achieved results. Wen Ying said with tears: "I am sorry for organizing many years of training, and I have given such an important position to me, and I But he stepped towards the abyss step by step..." Wen Ying regretted what he had done and took the initiative to explain all the facts of violation of discipline and law.

  It was verified that between January 2013 and July 2018, Wen Ying took advantage of his duties and received 14 hospitals and other hospitals in fourteen times, and the cash sent by Mr. Zhang totaled 1.279 million yuan in cash.

  In 2017, as a result of receiving reports of fraudulent insurance behavior by the academic hospital, the Municipal People's Social Security Bureau Fund Office went to the academic hospital for audit. The Supervision Section of the Nan'an District Social Security Bureau also began to examine the academic hospital and asked the academic hospital to provide 1,000 medical records. After accepting the benefits of Liang Mou and Zhang Mou, Wen Ying instructed the Supervision Section of the Social Security Bureau of the district not to seriously cooperate with the Fund Office of the Municipal Human Resources and Social Security Bureau, so as to delay the investigation of the academic hospital, resulting in the investigation being in the form of no investigation. Going to the hospital to defraud the truth.

  Investigators carried out in-depth investigations. Subsequently, the violation of discipline and law by 133 party members and cadres and public officials gradually surfaced, and the interest chain of deception of academic hospitals was also exposed to the sun. After investigation, from 2013 to 2017, the Nanan District Academy Hospital illegally recruited patients, provided false medical records, and tampered with information and data to defraud the medical insurance fund of 14.29 million yuan.

  The two-level Discipline Inspection and Supervision Commission in the urban area digs deep into the corruption and style behind the case, and uses the "four forms" of supervision and discipline to deal with 133 people, of which the first form deals with 100 people; 5 accountable party organizations and leading cadres of party members 20 people.

  Check the flow to enlarge the regulatory gap

  The loss of Wen Ying’s defense line of thought opened up a “gap” for criminals to defraud social security funds.

  From a teacher to a cadre at the current level, Wen Ying gradually grew up under the training of the organization, but after she had the power in her hands, the line of defense she once adhered to gradually became blurred.

  As the main leader of the medical insurance fund supervision department, Wen Ying did not converge or withdraw after the 18th National Congress of the Communist Party of China. He repeatedly accepted banquets and gifts from management service objects, violating the spirit of the eight central regulations; Friends, it is obviously unfair and violates the discipline of the people; irresponsible in work, neglected management, resulting in the national huge medical insurance fund being scammed by the academic hospital, violation of work discipline; extravagant life, greed for pleasure, violation of life discipline. Wen Ying also took advantage of his position to accept bribes.

  "In the beginning, when the management client sent the red envelope, Wen Ying did not accept it. Once it was received and then returned, and once it was returned three times, and the others delivered it again, and finally she accepted it. The case handler told reporters.

  "My world outlook, outlook on life, and values ​​are out of order. In a complicated environment, I gradually lost my way." Wen Ying wrote in his confession book that he did not dig deeply into some unlawful acts and did not promptly To curb the violations of laws and regulations in the medical system has caused great harm to the medical insurance in Nan'an District. "Due to poor supervision and serious loss of control, the medical insurance fund has become the "Tang Seng meat" of unscrupulous businessmen, and it has gradually corrupted and fallen into a slave of money."

  "Party cadres in the regulatory department are in frequent contact with the regulatory objects. If the regulatory power is not restricted, there may be corruption issues such as power and money transactions, and even acting as an "protection umbrella." Deputy Director of the Integrity Research and Education Center of Beijing University of Aeronautics and Astronautics Du Zhizhou said.

  It was Wen Ying who opened the "notch", but there were many people who enlarged the "notch". The Commission for Discipline Inspection of Chongqing Municipality systematically sorted out the road map for the fraudulent insurance of the hospitals in Nanan District, comprehensively analyzed the outstanding problems and the reasons revealed by the case, and found that the lack of overall planning and insufficient regulatory rigidity was another reason for the case.

  The fraudulent and deceptive behavior of academic hospitals has not been discovered for a long time. The important reason is that party members and cadres and public officials of some regulatory departments have received gifts and even bribes, which has caused supervision to be formalized. People from the original district Human Resources and Social Security Bureau, the original district health and planning commission, the original district food and drug supervision branch bureau, and the district public security branch bureau all have personnel involved in the case.

  "Strengthening the supervision of the medical insurance fund should integrate the supervision of doctors' diagnosis and treatment, the purchase and sale of medical consumables, and the use of medical insurance funds to form a strict mechanism and a complete system for the entire chain and all-round supervision." The case reflects that the relevant industry competent departments are in charge of each other, each has its own policies, and insufficient information sharing and intercommunication, failing to fully reflect the overall supervision efficiency, allowing some hospitals to avoid systematic supervision through systematic fraud. "The supervision power of the relevant industry competent authorities is weak, and the scope of supervision targets is multifaceted and continues to grow. On-site inspections are often sloppy and formal."

  The supervision chain is not strict and incomplete, and the sharing of supervision information is not smooth, resulting in the exchange of interests and the failure of supervision. Du Zhizhou believes that in this situation, the supervisory body may have a fluke, resulting in the failure of the supervisory defense line.

  Correcting the fourth case to protect the people's life-saving money

  “Academic hospital fraud insurance cases involve a large number of people, huge amounts, and bad nature. In order to give full play to the root cause of investigating and handling cases, we cooperated with the Municipal Commission for Discipline Inspection to carry out special investigations. After analysis, it was found that recruiting patients illegally, inflating projects, and smoothing out sales Cao Hong, a deputy secretary of the Nan'an District Discipline Inspection Commission and deputy director of the District Supervision Commission, said that false reporting, cashing out, evading supervision, etc. are not the only cases in medical insurance agreement hospitals.

  According to the deployment of the Municipal Party Committee and under the guidance of the Municipal Commission for Discipline Inspection, the Nan'an District, the Municipal Medical Security Bureau, and the Municipal Health and Health Commission took the medical insurance disorder exposed in this case as an entry point, and carried out the "Supervision, case-based reform system, case-based reform style" pilot work, exploring the responsibilities and tasks that party committees, disciplinary inspection and supervision agencies, and functional supervision departments should undertake in "case-based four reforms" to promote the effectiveness of subject responsibility, supervision responsibility, and supervision responsibility Throughout, we will advance together and dare not rot, not rot, or do not want to rot, and deepen both the symptoms and the root cause.

  The Nan'an District Committee took the main responsibility, and promoted the competent departments to improve the coordinated supervision mechanism, internal control mechanism, and access and exit mechanisms for medical institutions, so as to timely plug the loopholes in the supervision mechanism.

  Using scientific and technological means to assist in supervision, the district took the lead in establishing a smart medical insurance audit system in Chongqing City, using big data, blockchain and other technologies to capture the original data of various departments and hospitals, focusing on solving the problem of information barriers.

  "The smart medical insurance review system is an important measure to promote the "out of the four cases in the case" and "from the case to the case" in order to promote the transition from the supervision of the medical insurance fund to the control of the incident and the reminder in advance." Nanan District Introduction by the relevant person in charge of the Medical Security Bureau.

  In response to the problems exposed by the case, the Nan'an District Commission for Discipline Inspection supervised the relevant units to start with the system, refine the seven work processes such as internal rotation communication, supervision and inspection, and case review, and establish designated medical institutions and medical insurance doctor score management, blacklists, etc. System to strengthen daily supervision and management of designated medical institutions and practitioners.

  The District Supervision Committee issued supervision proposals to the four key involved units, including the original District Human Resources and Social Security Bureau, the original District Health and Planning Commission, the original District Food and Drug Administration Bureau, and the District Public Security Branch Bureau, from risk prevention and control, internal supervision, system construction, and integrity education. To make recommendations.

  In accordance with the requirements of the supervision proposal to promote the reform of the case, the District Medical Security Bureau, together with the health and health, market supervision, and public security departments, established 10 inter-departmental joint law enforcement inspection teams to focus on forged medical records, bed hospitalization, fictitious medical treatment, and excessive diagnosis and treatment. In response to 31 specific violations of rules, disciplines and laws, special governance will be carried out throughout the district. The Joint Law Enforcement Inspection Team inspected 821 designated agreement agencies on site, and handled a total of 344 medical insurance violations and breaches of contract, involving funds of 118 million yuan.

  The case was investigated and dealt with, and the supervisory committee of the Nan'an District Commission for Discipline Inspection also filmed Wen Ying's serious violation of discipline and law into a warning educational film, assisting the district committee to carry out "discipline, case, and case" at all levels in the district. Virtue and blame by case" warns education, clarifies the problem clearly, clarifies responsibilities, and educates people around by case.

  It is understood that since the implementation of the "reform of the four cases" and "the theory of the four cases of the case" were implemented, a group of party cadres in the Nanan District took the initiative to clarify the problem to the party organization of their unit and made a profound review to the party organization on their own non-compliance.

  If there is a problem with the primary medical institution, what about the situation of the superior leadership and the regulatory department? In response to the problems of incoordination and non-cohesion between the various systems reflected in this case, as well as defects in some systems, the Chongqing Municipal Commission for Discipline Inspection supervised the Municipal Health and Health Commission and the Municipal Medical Security Bureau to seize the functional adjustments of relevant departments after institutional reform and " Take the dual opportunity of "four cases of reform", take the responsibility of the main body, and strengthen the design of the top-level system.

  "Before the establishment of the Medical Insurance Bureau, many medical insurance policies were scattered in different departmental regulations. We and the Municipal Health and Health Commission introduced college professional teams to jointly set up work teams to comprehensively clean up and integrate the 268 medical insurance regulatory documents issued by various departments. "The relevant person in charge of the Chongqing Municipal Medical Security Bureau said: "We have summarized the original scattered, messy and chaotic rules, and sorted out the clear tree-shaped rules, which are clear at a glance." At present, the work has been improved 8 administrative The list of powers and 16 items of public services is instructing districts and counties to improve the implementation process and online operation of the two lists.

  The Chongqing Municipal Medical Security Bureau and the Municipal Health and Health Commission are also deploying special operations to combat fraud and fraud in the city. A total of 1520 medical insurance services were suspended, 537 fixed-point agreements were lifted, 407 administrative penalties were handed over, 148 were transferred to judicial organs, and 593 cases of typical problems were reported through the media, creating a strong deterrent in the city. (Reporter Lu Lihuan)