"But drugs and consumables are different. Because patients can get the medicine immediately, they can see the manufacturer and other information on the package. If the wrong medicine is given, the patient is undoubtedly unwilling, but brain surgery consumables are widely used in clinic, and most of them are expensive. Patients lying on the operating table can't see what consumables are used, and some hospitals will tamper with them more conveniently. Drugs are generally based on the wrong diagnosis and prescription. " Zhong Chongming said.
So what does "low-value medical equipment and consumables for brain surgery" announced by the National Medical Insurance Bureau mean? According to statistics, the key to the exchange of drugs, medical equipment and consumables, diagnosis and treatment projects and public service facilities refers to the behavior of individuals to plan the projects of drugs, medical equipment and consumables, diagnosis and treatment projects and public service facilities that do not meet the scope of medical insurance payment in the national medical insurance catalogue and bring them into the liquidation category, thus defrauding the medical insurance fund.
For example, from May 2065438 to May 2009, Nanjing Medical Insurance Bureau informed Taikang Xianlin Gulou Hospital of his personal exchange of medical materials, involving O2 aerosol masks. The payment details are marked with the word "Import", and the charging standard is 37 yuan, accounting for 40% of the expenses, but the patient specially used another simple sprayer made in China.
It is worth noting that brain surgery seems to be a frequent area of insurance fraud: in August of 20021,the information of Henan Provincial Medical Insurance Bureau showed that the Department of Brain Surgery and Bone Tuberculosis of Zhengzhou Sixth People's Hospital implanted 459 common pedicle screws for patients within one year, but recruited, filed, labeled and charged according to minimally invasive pedicle screws (long tail keyword type), because they were suspected of defrauding insurance with fake documents. On June 5438+ 10, 2022, according to the notice of Beijing Medical Insurance Bureau, Beijing Qianhai Femoral Head Hospital defrauded the social insurance fund by fraud, forged documents or other means, and was fined about 654.38+42 million yuan.
Another analysis shows that in addition to replacing medical equipment and consumables, in the case of fraudulent insurance, some hospitals know that China has repeatedly prohibited the reuse of disposable medical equipment, but they still let patients use it, and deduct the same expenses as the newly upgraded medical equipment, and take the normal reimbursement system to defraud the medical insurance fund. The Supreme Court has analyzed that from the perspective of criminal cases of insurance fraud, the key is to present three levels of characteristics.
First, the subject of crime is diversified. The main body of fraudulent insurance is not only designated hospitals, retail pharmacies and insured persons, but also medical insurance cards or drug purchasers. Some cases also involve staff of the medical insurance bureau.
Zhong Chongming also reported on the economic development in the 2 1 new century: "fraudulent insurance is likely to involve doctors, hospitals, patients and other staff. For example, the application of consumables involves inventory recording. What if there is cross-exchange? The inventory data information is different, and it is likely to involve relevant staff at the inventory level. "
Second, the ways of committing crimes are diversified. Not only do designated medical institutions or social security payers falsify medical history and documents, falsely report expenses for reimbursement or change new diagnosis and treatment items, and falsely report inspection expenses, but also social security payers pretend to be other people's medical insurance cards, sell them after purchasing drugs in excess, repeatedly reimburse or conceal medical expenses, which does not belong to the scope of basic medical insurance fund payment. Some cases also involve state officials taking advantage of their positions to misappropriate medical insurance funds.
Third, the consequences of injury are very serious, and the criminal offence of medical insurance fraud is very secret. Some cases have a long cycle, frequent crimes and a large number of people involved, which seriously jeopardizes the sustainable development trend of the medical and health system.
According to the data released by the National Medical Insurance Bureau, 708,000 designated pharmaceutical institutions were inspected in 20021* *, and 46,543,800 illegal institutions were solved. By the end of 20021,* * recovered medical insurance assets of 23.41.80 billion yuan. In-depth flight inspections were conducted for 30 times, and 68 designated medical insurance hospitals and 30 medical insurance agencies in 29 provinces and cities were specifically inspected, and 558 million yuan of assets suspected of violating laws and regulations were found.
According to the relevant data, in official website, Ministry of Health Insurance and Social Security, financial audit and health human resource management, we searched for cases that have been rectified from 20 16 to 2020, and there are 494 classic cases. According to the survey, there were 139 cases rectified before the establishment of the national medical insurance bureau, and there were 165 cases after the establishment.