Part of the three hospitals in the beds, health services, drugs and consumables to do some action in the field of relative sex is very easy, but due to the lower price of health services, there is no need to do tampering, and the big three beds are very anxious, very few time beds, then the space of false reporting hospitalization is less, so part of the hospital is very likely to be based on the drugs, consumables to carry out fraudulent insurance, what department of medicine, using The situation will be a little more serious when the relative nature of the consumables is more.
"But drugs and consumables are not the same, because the patient can immediately obtain the drug, can see the manufacturer on the packaging and other information content, if given the wrong medicine, the patient is undoubtedly reluctant, but the brain surgery consumables are generally applied in the clinic and most of the price is high, the patient lying on the operating table to see the application of which consumables, a portion of the hospitals to do tricks It will be more convenient, the drug is generally based on false diagnosis, prescription, etc. to carry out insurance fraud." Zhong Chongming spoke.
So what does the National Health Insurance Bureau circular "collusion, false record of brain surgery low-value medical equipment supplies" stand for? According to statistics, the key to swap drugs, medical equipment supplies, diagnosis and treatment items and public **** service facilities is to refer to the drugs, medical equipment supplies, diagnosis and treatment items and public **** service facilities that do not meet the scope of payment of medical insurance for the national health insurance catalog of the project planning, included in the scope of the liquidation, and then fraudulently claimed the medical insurance fund of individual behavior.
For example, in May 2019, the Nanjing Municipal Health Insurance Bureau notified Taikang Xianlin Gulou Hospital of the individual behavior of collusion of medical materials, involving the O2 nebulizing mask, the details of the payment marked "imported" words, the charge of 37 yuan, the out-of-pocket accounted for 40%, but the patient specifically used another domestic simple spray machine.
It is worth noting that the brain surgery seems to be fraudulent insurance area: in August 2021, according to the Henan Provincial Medical Insurance Bureau information content, Zhengzhou City, the Sixth People's Hospital Brain Surgery, Bone Tuberculosis Section in one year for the patient embedded in the 459 general pedicle screws, but in accordance with minimally invasive surgical pedicle screws (long-tailed keywords) to carry out the acquisition of recruiting, filing, labeling, charging rates, due to the suspicion of false documentation method to fraudulently receive the insurance. The method of false supporting documents to fraudulently claim the expenditure of the medical insurance fund, involving more than 1.74 million yuan; in January 2022, according to the Beijing Municipal Bureau of Medical Insurance notice, the Beijing Qianhai femoral head hospital fraudulently claimed the expenditure of the social insurance fund by fraud, imitation of supporting documents or other methods, and was penalized with a penalty of about 142 million yuan.
Another analysis shows that, in addition to the serial exchange of medical equipment and supplies, in the case of fraudulent insurance, part of the hospital knows that China is strictly prohibited from repeated use of disposable medical equipment, but still let the patient to apply, and deduct the same cost with the new upgraded medical equipment, go through the normal reimbursement system, in order to fraudulently claim the health insurance fund. The Supreme Court has analyzed, from the trial of criminal cases of insurance fraud, the key to show three levels of characteristics.
One is the diversification of the criminal subject, the subject of fraud not only medical insurance designated hospitals, retail pharmacies, participants, but also medical insurance card or drug buyers, part of the case also involves medical insurance bureau staff.
Zhong Chongming also indicated to the 21st New Century Economic Development Report: "Fraudulent insurance is likely to involve physicians, hospitals, patients, but also likely to involve other staff, for example, the application of consumables involves inventory records, if there is a series of exchange, inventory data information is not the same how to do, and therefore it is likely to involve the level of the inventory level of the relevant staff. "
The second is the diversification of illegal and criminal ways, not only the fixed-point medical institutions or social security payers imitation medical history, documents, false expense reimbursement or serial exchange of new items of diagnosis and treatment, false diagnosis and examination costs, but also social security payers posing as other people's health insurance card, overpurchase of drugs and then sold for profiteering, repeated cost reimbursement of medical expenses or concealment does not belong to the category of the basic medical insurance fund payments, part of the case also involves National public officials use their positions to embezzle health insurance funds.
Thirdly, the consequences of the harm is very serious, medical insurance fraud criminal offense hidden strong, part of the case cycle time is large, the frequency of illegal and criminal, the amount of people involved in the case is high, more serious harm to the health care system of the development trend of health care system.
According to the information released by the State Medical Insurance Bureau, in 2021 **** checked 708,000 and designated pharmaceutical organizations, solved 414,000 and violated the rules and regulations of the illegal organizations, as of the end of 2021, **** recovered medical insurance assets of 23.418 billion yuan. In-depth flight inspections were conducted in 30 groups, specifically checking 68 medical insurance designated hospitals and 30 organizations of medical insurance operators in 29 provinces and cities, and finding out RMB 558 million in assets due to suspected illegal violations of regulations.
According to the relevant data information, in the official website of the Ministry of Medical Insurance, Finance and Audit, Health and Health, and Human Resources Management and Social Security, the keywords "instances of insurance fraud" and "instances of fraud and insurance fraud" are used to search for the keywords, and retrieve examples of the 2016~2020 remedial measures that have been taken, and a number of them were found. 2020 has been remedied instances, a *** have 494 classic cases. According to the survey, the number of instances remediated before the creation of the NHPA was 139, and the number of instances after the creation of the NHPA increased significantly, with 165 cases.