China News Service, September 15th. According to the official WeChat news of the National Medical Insurance Administration, the Exposure Station of the National Medical Insurance Administration released the fifth phase of exposure of typical cases (10 cases) in 2021, and announced the details.
1. Insurance fraud case of the Sixth People's Hospital of Zhengzhou City, Henan Province
In April 2021, the Zhengzhou Medical Insurance Bureau of Henan Province investigated according to real-name reporting clues and found that the Sixth People's Hospital of Zhengzhou City had a problem that the surgical record of pedicle screw use was inconsistent with the actual implantation, resulting in a loss of 1,741,491.50 yuan in the medical insurance fund.
According to the "Social Insurance Law of the People's Republic of China", "Zhengzhou Medical Security Designated Medical Institution Service Agreement" and "Zhengzhou Basic Medical Insurance Designated Medical Institution Medical Insurance Physician Management Interim Measures", the local medical insurance department's handling results are as follows: 1. Cancel the hospital's orthopedic director Eligibility for payment of medical insurance services by Chen XX, director of the Department of Orthopedic Tuberculosis, Qian XX, etc.; 2. As of 0:00 on April 28, 2021, the medical insurance fund settlement of the Orthopedics and Orthopedics Department of the hospital will be suspended; 3. Recovery of losses The medical insurance fund was fined 5 times; 4. The clues about related issues were transferred to the Disciplinary Inspection and Supervision Group of the Municipal Health Commission, the Municipal Public Security Bureau, and the Municipal Market Supervision Bureau.
At present, the Disciplinary Inspection and Supervision Team of the Zhengzhou Municipal Commission for Discipline Inspection and Supervision assigned to the Municipal Health Commission has filed a case for review (investigation) by Chen Moumou, Director of Orthopedics Department of the hospital, and Lei Moumou, Section Chief of Medical Equipment Department; The clues were filed for investigation; the loss of the medical insurance fund of 1,741,491.50 yuan has been returned, and the five-time fine of 870,745.50 yuan has been fully implemented.
2. A case of violation of regulations in a hospital in Chifeng City, Inner Mongolia Autonomous Region
In August 2020, the Chifeng Medical Security Bureau of Inner Mongolia Autonomous Region transferred the Autonomous Region to the National Medical Security Bureau to report clues and found that Dou Moumou, director of the Rehabilitation Medicine Department of Chifeng Hospital, had illegal behaviors such as swapping project charges and inconsistent treatment items with the content of the project. Involving the medical insurance fund 1,485,982.16 yuan.
According to the "Chifeng City Basic Medical Insurance Designated Medical Institution Medical Service Agreement", the local medical insurance department handled the results as follows: 1. Suspending the medical insurance service payment qualification of Dou, the director of the rehabilitation medicine department of the hospital; 2. Recovering the illegal settlement of the hospital 3. The Chifeng Medical Security Bureau interviewed the Chifeng City Hospital, notified the hospital within Chifeng City and exposed it to the media; 4. Ordered the hospital to rectify the existing problems within a time limit, etc.
At present, the medical insurance fund 1,485,982.16 yuan settled by the hospital in violation of the regulations has been refunded.
3. Violation case of the Second Hospital of Fuzhou City, Fujian Province
In November 2020, an investigation by the joint task force of the Fujian Medical Insurance Bureau and the Fuzhou Medical Insurance Bureau revealed that the ultrasound physicians of the Fuzhou Second Hospital did not strictly audit the patients, resulting in illegal behaviors such as fraudulent medical treatment, involving a medical insurance fund of 37,478.56 yuan.
According to the "Fuzhou Basic Medical Insurance Violations Investigation and Punishment Measures", the local medical insurance department handled the results as follows: 1. Suspended the medical insurance service payment eligibility of 9 doctors in the hospital, including Lin, Peng, Gao, etc. for 3 months; 2. For the insured person involved in this case for more than 2 years of the administrative penalty, the counterfeit card fund will be recovered; for individual insured persons who have repeatedly counterfeited their card, the illegal fund will be recovered, included in the key supervision list, and medical insurance will be changed. Settlement method; 3. Recover the medical insurance fund that the hospital settled illegally.
At present, 37,478.56 yuan of the medical insurance fund that the hospital illegally settled has been refunded.
4. Violation of the Fourth People's Hospital of Sichuan Province
In February 2021, the Jinjiang District Medical Insurance Bureau of Chengdu, Sichuan Province, during a daily inspection of the Fourth People’s Hospital of Sichuan Province, found that there were unindicated examinations in the hospital, no report form for digital photography and film, general special care, ultrasound atomization, bladder The illegal settlement of medical insurance funds such as no doctor's advice or inconsistent medical advice and charges involved medical insurance fund of 24745.49 yuan.
According to the "Notice of the Chengdu Municipal Medical Insurance Administration on Strengthening the Management of Medical Insurance Physician Agreements", the local medical insurance department's handling results are as follows: 1. The hospital physician Zhang Moumou failed to record medical records in accordance with the "Basic Medical Record Writing Standards", and failed to accurately record medical records , Cao XX fails to perform the informed consent and signature system of the insured persons (family members) as required, and each deducts 1 point for the doctor’s points; 2. Recovers the medical insurance fund for illegal settlement, and deducts the liquidated damages according to the regulations; 3. Interviews the hospital to be responsible People, order rectification within a time limit, etc.
At present, the hospital’s medical insurance fund of 24745.49 yuan and liquidated damages have been paid in violation of the regulations.
5. Violation case of the First People's Hospital of Taizhou City, Zhejiang Province
In June 2020, the medical insurance department of Taizhou City, Zhejiang Province, during a routine inspection, found that Taizhou First People’s Hospital had bed-hanging hospitalization, disintegrated hospitalization, lowered admission standards, and admitted insured persons who did not meet the admission indications. The behavior involved 17,733.04 yuan from the medical insurance fund.
According to the "Zhejiang Province Medical Insurance Physician Agreement Management Implementation Rules" and "Taizhou Huangyan District Basic Medical Insurance Designated Medical Institution Service Agreement", the local medical insurance department handled the results as follows: 1. The insured person did not meet the admission criteria but admitted to the hospital. XX deducted 2 points, Ding XX deducted 2 points, and Huang XX deducted 4 points; 2. Recover the medical insurance fund for illegal settlement, and deduct liquidated damages as required.
At present, the hospital’s medical insurance fund of RMB 17,733.04 and liquidated damages for illegal settlement have all been paid.
VI. Violation of regulations by the Hospital of Traditional Chinese Medicine in Langfang City, Hebei Province
In August 2020, during a special inspection and inspection in the medical insurance field in Langfang City, Hebei Province, it was discovered that 9 doctors including Wang Moumou, Zhang Moumou, and Li Moumou from Langfang Traditional Chinese Medicine Hospital had illegally prescribed "big prescriptions", and there were some outpatient prescriptions. The prescription of drugs for the treatment of prostate cancer and other violations for female patients involved 2017176.16 yuan of medical insurance fund.
According to the "Langfang City Urban Medical Insurance Service Physician Management Measures", "Prescription Management Measures" and "Hebei Province Medical Insurance Designated Medical Institution Medical Service Agreement", the local medical insurance department's handling results are as follows: 1. Suspend Wang Moumou, Zhang Moumou, Li XX and other 9 doctors are eligible to pay for medical insurance services; 2. Stop the settlement of the medical insurance fund of the "Special Outpatient Clinic" of Langfang Traditional Chinese Medicine Hospital; 3. Recover the medical insurance funds that have been settled in violation of regulations; 4. The investigation and review process was initiated; 5. The clue was transferred to the local public security agency. The public security agency of Langfang City took compulsory measures against the five persons suspected of constituting a crime. The case is under further investigation.
At present, the medical insurance fund of 2017176.16 yuan that the hospital illegally settled has been refunded.
7. Violation case of Qinzhou Traditional Chinese Medicine Hospital in Guangxi Zhuang Autonomous Region
In May 2021, an investigation by the Guangxi Qinzhou Medical Insurance Bureau revealed that Qinzhou Traditional Chinese Medicine Hospital had problems such as swapping project charges, over-examination, and over-treatment from January 2020 to April 2021, involving the medical insurance fund of 1995547.80 yuan.
The investigation found that the above-mentioned violations were mainly caused by the weak concept of medical insurance laws and regulations for medical staff in the first district of the acupuncture and moxibustion department and the second district of the tuina department, and the confusion of patient management, especially the doctors Zhang, Zhao and Tuina in the first district of the acupuncture and moxibustion department. Eleven people, including Zhong Moumou and Han Moumou, in the second district of the department, did not earnestly perform their duties as a physician.
According to the "Notice of the Guangxi Zhuang Autonomous Region Human Resources and Social Security Department on Printing and Distributing the Interim Measures for the Management of Physicians in Designated Medical Institutions of Basic Medical Insurance in Guangxi" and the "Medical Service Agreement of Designated Medical Institutions of Basic Medical Insurance in Qinzhou", the local medical insurance department's processing results are as follows 1. Suspend the medical insurance service payment eligibility of 11 people including Zhang and Zhao in the first district of the acupuncture and moxibustion department of the hospital, and Zhong and Han in the second district of the Tuina department; 2. suspend the acupuncture and moxibustion department 1, 3 months of medical insurance fund settlement in the second district of Tuina Section; 3. Recovering the medical insurance fund used in violation of regulations; 4. Transferring clues to the hospital’s irregularities to the Municipal Commission for Discipline Inspection and so on.
At present, all the medical insurance funds settled by the hospital in violation of the regulations have been returned.
8. Violation of Xiangrui Rehabilitation Hospital for the Elderly in Liaoyuan City, Jilin Province
In April 2021, an investigation by the Liaoyuan Medical Insurance Bureau of Jilin Province found that Liaoyuan Xiangrui Geriatric Rehabilitation Hospital had unreasonable charges, unreasonable diagnosis and treatment, low-standard hospitalization, and over-range use of restricted medications and other illegal settlement of medical insurance funds, involving 1.05 million medical insurance funds Yuan.
According to the "Services of Designated Medical Institutions for Basic Medical Insurance in Liaoyuan City", the local medical insurance department's handling results are as follows: 1. The illegal doctors of the hospital suspended their medical insurance service payment eligibility for one year; 2. The hospital's illegal settlement of medical insurance funds was recovered. ; 3. Transfer the clues to the local public security organs, etc.
At present, the hospital’s 1.05 million yuan of medical insurance funds settled in violation of the regulations have all been recovered.
9. Violation case of Phoenix Hospital of Dongfang Hospital Group in Huainan City, Anhui Province
In January 2021, the flight inspection team of the Anhui Medical Insurance Bureau conducted a special spot check on the Phoenix Hospital of the Huainan Dongfang Hospital Group and found that the Phoenix Hospital of the Huainan Dongfang Hospital Group had illegal charges, unreasonable use of drugs, and alternation of medical insurance funds. , Involving the medical insurance fund of 676907.79 yuan.
According to the "Huainan City Medical Insurance Agreement Physician Management Implementation Rules (Trial)" and "Huinan City Basic Medical Insurance Hospitalization Designated Medical Institution Medical Service Agreement (Trial)", the local medical insurance department's processing results are as follows: 1. Deduction of the hospital's physician Zang a year The assessment score is 12 points, and the qualification for payment of medical insurance services for this year is suspended; 2. The medical insurance fund for illegal settlement of the hospital shall be recovered; 3. The hospital shall be ordered to make rectification within a time limit and submit a rectification report.
At present, all the 676,907.79 yuan of medical insurance funds settled by the hospital in violation of the regulations have been returned.
10. Violation of Zhongxintang Hospital of Traditional Chinese Medicine in Dalian City, Liaoning Province
In January 2021, after investigation by the Dalian Medical Insurance Bureau of Liaoning Province, it was discovered that six people including Wu, Zhao, Sun, Cheng, Zhou, and Gai, doctors from Zhongxintang Hospital of Traditional Chinese Medicine in Dalian City, had medical records, actual operation and Problems such as inconsistent medical expenses and lowering of hospitalization standards occurred.
Assistant physician Zhang's physician qualification certificate is a teacher or he does have expertise, and he should provide medical services under the guidance of a practicing physician. However, the physician independently conducts diagnosis and treatment activities, causing non-practicing physicians to upload fees.
The above questions involved a total of 104,109.7 yuan in the medical insurance fund.
According to the "Dalian Medical Insurance Designated Medical Institution Medical Service Agreement (2020 Edition)" and the "Dalian Medical Insurance Service Physician Management Measures", the local medical insurance department handled the results as follows: 1. The hospital doctors Wu, Zhao, Sun, 4 people including Cheng were given 4 points deduction, and 2 people including Zhou and Gai were deducted 8 points, and the assistant physician Zhang was transferred to the Health Bureau of Xigang District, Dalian City; 2. The hospital was suspended. Inpatient ward (first department of traditional Chinese medicine, second department of traditional Chinese medicine) 6 months of medical insurance fund settlement; 3. No settlement of the violation fees incurred and a reduction of 2 times, a total of 33,2529.1 yuan of illegal settlement medical insurance funds will be recovered; 4. The hospital shall be ordered to have a deadline Rectification and so on.
At present, all the medical insurance funds settled by the hospital in violation of the regulations have been returned.
The Xigang District Health Bureau of Dalian City imposed a fine of 3,000 yuan on the hospital’s assistant physician Zhang and an administrative penalty of six months’ suspension of practice.