I. Counterfeit medical service invoices and fraudulent use of the medical insurance fund
The patient falsely issues invoices for medical treatment and purchase of medicines through acquaintances and submits the related invoices to the medical insurance agency to declare the manual reimbursement of the incidental reimbursement by forging the medical records of the medical treatment.Second, the medical insurance identification credentials will be lent to other people for medical treatment, or the medical insurance identification credentials of other people under false names
1. I have medical insurance arrears, the treatment waiting period for the need for medical treatment, the use of their relatives social security card for medical treatment, purchase of medicines.2. If you have a relative who is serving a prison sentence, you can use your relative's social security card for hospitalization reimbursement.
Third, the illegal use of health insurance identification credentials, the use of medicines and supplies
The patient to take advantage of uremia dialysis door special reimbursement ratio of the treatment characteristics of long-term prescription of hypertension, diabetes drugs to other patients suffering from hypertension, diabetes and other chronic diseases use behavior.Four, involving other fraudulent insurance participants
1. patients in foreign provinces have employee health insurance treatment, in Xuzhou City and repeat participation in the urban and rural residents health insurance, its hospitalization in the field after the card settlement, and then take the relevant bills to the Xuzhou City health insurance agency to apply for manual sporadic reimbursement. 2. After the traffic accident, the traffic police found that the at-fault party is fully responsible for the at-fault party and the injured party to negotiate privately, to give a certain amount of financial compensation for the injured party to use the hospitalization reimbursement of health insurance. The injured party in the trauma investigation process deliberately conceal the process of injury, the use of medical insurance for reimbursement.Medical institutions
A violation of the diagnostic and treatment norms of over-diagnosis and treatment, excessive examination behavior
1. In a single hospitalization, non-essential repeat blood type, lipids, tumor markers and other test items. 2. The same part of the simultaneous charging of traditional Chinese medicine fumigation treatment, traditional Chinese medicine steam bath treatment, traditional Chinese medicine fumigation treatment costs. 3. Non-rehabilitation inpatient hospitals, charging the cost of rehabilitation assessment, such as charging the cost of "daily living capacity assessment. 4. Other excessive medical behaviors recognized by the health department.Second, in violation of the price regulations, repeat charges, over-standard charges, decomposition of the project charges
1. Nursing fees, bed fees should be calculated in accordance with the method of counting in and not counting out, over the number of days of hospitalization, bed fees, nursing fees. 2. Oxygen inhalation fees are charged in excess of the length of hospitalization, and the daily charge for oxygen inhalation exceeds the $65 cap. 3. For critical care or intensive care, a separate fee will be charged for each specialized care. 4. When intravenous infusion is performed, a fee is charged for the materials included, such as disposable infusion sets, single-use dispensing syringes, etc. 5. 5. The use of indwelling needles to carry out intravenous infusion, a separate charge for "venipuncture catheterization", "arterial catheterization care". 6. When compounded amino acids, fat-soluble vitamins, etc. are used for separate infusion, the fee for "intravenous high-nutrition therapy" will be charged. 7. When charging for sputum suction care, repeat the charge for "mechanically assisted sputum evacuation". 8. Nursing care fee includes the measurement of patients' temperature, pulse, blood pressure, respiration and other vital signs monitoring, repeat the charge of temperature, pulse, blood pressure, respiration and other measurement costs. 9. "Cardiac color Doppler ultrasound" examination, separately charged "general cardiac M-mode ultrasound" "general two-dimensional echocardiography" costs. 10. For bedside ultrasound, the fee for routine ultrasound examination is repeated. 11. The same ultrasound project, at the same time charged "color film report" and "computer graphic report" fees. 12. The same ultrasound program, both "computer graphic report" and "color prints" fees. 13. Carry out general color Doppler ultrasound, should be "part" of the pricing charges, not according to the number of organs, each blood vessel, etc. pricing charges; to carry out color Doppler ultrasound of blood vessels in the extremities, should be "per limb" pricing charges, not according to the Each blood vessel and other decomposition charges. 14. In addition to color Doppler ultrasound of the blood vessels of the neck (including the carotid artery, jugular vein, vertebral artery, subclavian artery), color Doppler ultrasound special examination is charged on a per-vessel basis. 15. "ABO blood group identification (card method)" examination, at the same time charge "RHD blood group identification" fee. 16. "General anesthesia", repeated charges "tracheal intubation" "special method of tracheal intubation". 17. "Cardiac monitoring", the same time period charged "dynamic blood pressure monitoring. 18. Transvascular intervention, repeated charges for local infiltration anesthesia, puncture, injection, tube placement, etc. 19. 19. To carry out endoscopic treatment, repeat the endoscopy fees. 20. To carry out a digestive endoscopy through the mouth or nose, according to the nasal endoscopy, laryngoscopy, tracheoscopy, and other multiple examinations. 21. Surgical treatment program name "XX mirror XX operation", repeat the "minimally invasive surgery plus charges" and a variety of luminal additional charges. 22. To carry out various types of exploration surgery, only for preoperative diagnosis is not clear or surgery can not be completed during the original surgery and interrupted surgery, not with other surgical items at the same time charges. 23. To carry out low-frequency, mid-frequency pulse electrotherapy, Chinese medicine directional transdermal therapy, should be charged according to the "each part" charge, according to the number of electrode patches to calculate the duplication of charges. 24. The same limb of an air pressure treatment process is broken down into multiple parts of the charge. 25. Surgical items included in the content of the conventional instruments and low-value medical consumables double billing (such as, disposable sterile towels, syringes, rinse saline, general sutures, dressings, etc.). 26. "Monitoring during anesthesia" includes end-expiratory carbon dioxide measurement, which is double billed as "carbon dioxide response curve". 27. Other irregularities in charging behavior identified by the price authorities.Three, the series of drugs, pharmaceutical supplies, diagnostic projects and services
1. Carry out the ordinary larger specimens of pathology and diagnosis, the series of the "whole-organ large slice of the pathology and diagnosis" charges. 2. To carry out genetic testing of drugs, crosstalk for the pathology examination program "blot hybridization technology" "in situ hybridization technology" and other charges. 3. Pain care assessment, crossover in accordance with the "comprehensive assessment of pain" charges. 4. Health education and promotion, in exchange for the "guided education and training" fee. 5. Will not be able to charge the project series exchange in accordance with the "special materials" to charge. (Such as: disposable laminar flow hood, disposable maternity bag, disposable dressing bag, care package, tape printing wristbands, skin preparation kit, specimen bags, medical sterile protective sleeve, nursing pads, calcium lime, disposable sterilized gloves, microscope sets, decompression stickers, gynecological materials, surgical rinses, disposable orthopedic surgical kit, disposable surgical kit, disposable nail box, and so on). 6. Nasogastric injection of food and medicine, the series replaced by "enteral high-nutritional therapy" charges. 7. To carry out serum albumin determination, glucose determination, potassium determination, sodium determination and other wet chemical tests, series for dry chemical method charges. 8. Red light irradiation, blue light irradiation and other "visible light therapy", series for "laser therapy" charges. 9. Post-operative use of "analgesic devices" (Category C), the series of charges in accordance with the "automatic injection pump" (Category B).Four, will not belong to the medical insurance fund to pay for the scope of medical expenses into the medical insurance fund settlement
1. Drugs over the medical insurance payment limit (1) injectable thymofaxine and injectable botulinum toxin A limited to the use of work-related injuries, over the payment of the use of the medical insurance fund to reimburse the medical insurance fund. (2) Cefathiamidine for injection is limited to patients with clear evidence of drug sensitivity tests or severe infections, and is reimbursed by the health insurance fund for overpayment. (3) Reimbursement of rabeprazole sodium for injection is limited to patients with a diagnosis of the disease as indicated in the insert and who have a medical prescription for fasting or dysphagia, and is reimbursed by the health insurance fund for overpayment. (4) Mecobalamin for injection is limited to patients with vitamin B12-deficient megaloblastic anemia who are unable to use the oral formulation of megalocobalamin due to fasting or dysphagia, and is reimbursed by Medicare using the Medicare fund for overpayment. 2. Diagnostic and therapeutic items over the scope of charges (1) non-infectious disease patients are charged "disposable tourniquet" fee. (2) Pediatric intravenous infusion refers to pre-school (up to 6 years of age) children, children over 6 years of age to charge for the program. (3) Special infectious diseases such as gas gangrene, tetanus, AIDS, etc. are not charged as "Special Disease Care".V. Inducing, assisting others to impersonate or false medical treatment, purchase of medicines, provide false documents, fictitious medical services
1. Doctors in the knowledge that the actual diagnosis and treatment of the patient is a child, but still issued an adult prescription, the use of adult health insurance card for children to medical treatment, purchase of medicines behavior. 2. The hospital charged patients for "waxing" during the period when the waxing machine was damaged, even though it was a fictitious medical service. 3. CT examination is not carried out blood vessels, gallbladder, CTVE, heart, brain, bone three-dimensional imaging, but charge "CT imaging" fees.Designated pharmacies
I. Theft of medical insurance identification credentials, for the participants to obtain cash or purchase nutritional supplements, cosmetics, household goods and other non-medical items
1. Pharmacy staff to see a lot of participants in the balance of the card in the event of the participant is unaware of the situation The first is to make sure that you have a good understanding of the situation, and that you have a good understanding of the situation, and that you have a good understanding of the situation. 2. Pharmacy staff empty brush the amount of the individual account of the participant's medical card, with the participant in accordance with the proportion of the share of cash. 3. Pharmacy staff will be cash sales of health, cosmetics and masks, povidone and other consumer goods using the personal account card settlement.Two, for the participants in the exchange of drugs, consumables, items and other fraudulent expenditure of the medical insurance fund
1. Pharmacy staff in order to allow participants to accumulate enough threshold fee and brush the integrated fund to facilitate the actual purchase of the patient's B drugs were swapped for A drugs for the brush. 2. Patients purchased blood pressure monitors, thermometers and other equipment and supplies, and the staff swiped the card according to the general reimbursable drugs.Three, for non-designated medical institutions to provide card settlement services
1. Pharmaceutical chain companies, in the knowledge that the new pharmacy has not yet applied for medical insurance designated, the first sale of medicines, and then take the insured person's medical card to the designated chain of pharmacies to settle.2. In the knowledge that the newly opened pharmacy has not yet applied for the designated medical insurance, the private pulling of the designated pharmacy's credit card line for credit card settlement.
Four, for the participants of false invoices, provide false invoices
Participants within the unit at the end of the second reimbursement policy, the medical institutions in order to cooperate with the participants to enjoy the corresponding treatment, in the case of the actual did not occur in the medical services, in advance, or empty swipe the card, to provide invoices for the purchase of drugs.Fifth, the designated retail pharmacies and their staff of other violations
1. swiped the card before the sale of cardholders did not check the identity of the cardholder information, resulting in the loss of the insured person's medical card was used by others under false pretenses. 2. Pepper, anise, black sesame, jujube and other medicinal herbs, the medical insurance is limited to the use of separate will not be paid for, and all of these tablets composed of prescriptions will not be paid. The designated retail pharmacies and their staff violated the restrictive requirements and allowed the insured to settle the payment by credit card.