Jilin Provincial Medical Insurance Bureau latest briefing!

Recently, the Jilin Provincial Bureau of Medical Security exposure 2021 to combat fraud and insurance special action cases (second batch). In accordance with the National Medical Security Bureau and the provincial medical security bureau 2021 fund supervision special governance work deployment, medical security departments around the world continue to increase the fight against fraud fraud insurance work, investigated and dealt with a large number of cases of violations, to maintain a high-pressure situation to combat fraud fraud insurance. In order to play a warning role in education, is now selected from the twenty-six cases of non-compliance with the use of medical insurance fund, for public exposure.

First, Dewei Misako Huikang Hospital violation case

After investigation, Dewei Misako Huikang Hospital, there is a super product use scope of treatment programs, super medical insurance restrictions on the use of drugs, no indication of the use of medication, unreasonable charges, directory against the wrong and other issues, involving the health insurance fund of 6.516 million yuan. The local medical insurance department in accordance with the "2020 Dewei city medical insurance designated medical institutions service agreement", made the following treatment: 1. interview the main person in charge of the hospital, and ordered rectification; 2. recovery of irregular use of medical insurance fund 6.516 million yuan.

Second, Jiutai Baohua Rehabilitation Hospital violation case

After investigation, Jiutai Baohua Rehabilitation Hospital exists in the scope of the use of exercise therapy and for patients who do not meet the first level of care indications to carry out the first level of care and so on, involving the health insurance fund 47.01 million yuan. The local health insurance department in accordance with the "2021 Changchun City Jiutai District health insurance designated medical institutions medical service agreement" Article 66, made the following treatment: 1. the hospital director for interview, ordered immediate rectification; 2. refused to pay the illegal use of health insurance fund 470,100 yuan.

Third, Changchun Shuangyang Hongqiao Hospital violation case

After investigation, Changchun Shuangyang Hongqiao Hospital, there are super medical insurance catalog limitations on the scope of medication, unreasonable charges, involving the medical insurance fund 44.88 million yuan. The local health insurance department in accordance with the "2020 Changchun City health insurance designated medical institutions medical service agreement" Article 7, Article 23, Article 26, Article 62, made the following treatment: 1. the hospital director for interviews, rectification within a limited period of time; 2. refused to pay the violation of the use of health insurance fund 44.88 million yuan.

Fourth, Changchun Hengshi Pharmacy Co., Ltd. violation of the case

After investigation, Changchun Hengshi Pharmacy Co., Ltd. exists for the non-designated pharmaceutical organizations or in the suspension of health insurance service agreement period of the pharmaceutical organizations to provide health insurance cost settlement problems.

The local health insurance department, according to the "Changchun City Medical Insurance Designated Retail Pharmacy Service Agreement (2021 years)" Article 43 and "2021 Changchun City Medical Insurance Designated Retail Pharmacy Assessment Rules (provisional)" Article 1, made the following treatment: 1. Deduction of the annual assessment points 10 points; 2. Dismissal of the health insurance service agreement.

V. Shulan Huimin Hospital irregularities

It was found that Shulan Huimin Hospital has low indications of admission, excessive charges, drugs and consumables do not match the actual sales and other issues, involving health insurance fund 29.92 million yuan. The local health insurance department in accordance with the "2020 Shulan City health insurance designated medical institutions service agreement" Article 64 (4), (7) and Article 65 (10), made the following treatment: 1. Recover the illegal use of health insurance fund 29.92 million yuan; 2. Interview with the person in charge of the hospital, and ordered to rectify the situation.

Six, Yongji County, Hong Yu Pharmacy six stores violations

After investigation, Yongji County, Hong Yu Pharmacy six stores there are sales of drugs uploaded information and the actual sales of medical insurance does not match the problem, involving the medical insurance fund of 18.16 million yuan. The local health insurance department in accordance with the "2020 Yongji County urban workers basic medical insurance designated retail pharmacy service agreement" Article 48 (2), made the following treatment: 1. Recover the illegal use of health insurance fund 181,600 yuan; 2. Suspension of the health insurance settlement for three months; 3. Interview with the person in charge of the pharmacy, and ordered to rectify the situation; 4. In the whole county designated medical institutions within the scope of the notification.

VII, Jilin City, Changyi District, Yan Nian Pharmacy violation case

After investigation, Jilin City, Changyi District, Yan Nian Pharmacy sales of medicines uploaded by the health insurance information does not match the actual sales of the problem, involving the health insurance fund of 22.04 million yuan. The local health insurance department in accordance with the "2020 Jilin City health insurance designated retail pharmacy service agreement" Article 48 (2), made the following treatment: 1. refused to pay the illegal use of health insurance fund 220,400 yuan; 2. suspended the health insurance settlement for three months; 3. interviewed the person in charge of the pharmacy, and ordered to rectify.

Eight, Guodai Yiho Pharmacy Jilin Co., Ltd. Itong Shunfa branch violations

After investigation, Guodai Yiho Pharmacy Jilin Co., Ltd. Itong Shunfa branch of the existence of the string of drugs arbitrage health insurance fund violations, involving health insurance fund 56,000 yuan. The local health insurance department in accordance with the "2020 Yitong Manchu Autonomous County basic health insurance designated pharmacy medical institutions service agreement" provisions, to deal with the following: 1. Interview the main person in charge of the pharmacy, and ordered to rectify; 2. Suspension of health insurance services for three months; 3. Recovering the illegal use of the health insurance fund of 55.6 million yuan.

IX, Siping City, the integrity of Yonghong Pharmacy Chain Co., Ltd. Tiedong branch violations

investigation, Siping City, the integrity of Yonghong Pharmacy Chain Co., Ltd. Tiedong branch of the existence of a series of drugs and other serious problems, the local health insurance department in accordance with the "2020 Jilin Province, the basic medical insurance designated pharmacy service agreement" relevant provisions, to make the following treatment: 1. refused to pay the full deposit and reserved funds 882,300 yuan; 2. refused to pay the illegal use of health insurance funds 794,900 yuan; 3. recovery of the loss of health insurance funds caused by 147,700 yuan; 4. termination of the health insurance service agreement, and shall not apply for three years of health insurance designated medical institutions.

X. Liaoyuan Huagang Hospital irregularities

It was found that Liaoyuan Huagang Hospital has a low standard of hospitalization, ultra-restricted use of medicines, the use of drugs retail price exceeding the standard, financial data is not true, the account does not match, the account does not match, etc., involving the health insurance fund of 2.543939 million yuan. The local health insurance department, in accordance with the relevant provisions of Articles 65 and 67 of the 2020 Liaoyuan City Health Insurance Designated Medical Institutions Medical Service Agreement, made the following treatments: 1. refused to pay the 2,543,900 yuan of illegal use of the health insurance fund; 2. suspended the hospital's health insurance services and transferred the case to the public security organs for processing. At present, the public security organs have been filed, the case is being investigated.

eleven, Liaoyuan Xiangrui geriatric rehabilitation hospital irregularities

investigated, Liaoyuan Xiangrui geriatric rehabilitation hospital duplication of medication, duplication of hospitalization and drug accounts do not match the problems, involving the health insurance fund of 1,053,600 yuan. The local health insurance department in accordance with the "2020 Liaoyuan City health insurance designated medical institutions medical service agreement" Article 65, made the following treatment: 1. refused to pay the violation of the use of health insurance fund of 1,053,600 yuan; 2. suspension of the health insurance service for three months; 3. deducted the health insurance physician Liu Mou, Guo Mouna, Hou Mouya full year of all the health insurance physician points, suspended the qualification of health insurance physician for one year.

XII, Liaoyuan Renai Hospital irregularities

After investigation, Liaoyuan Renai Hospital, there are excessive standards of medication, excessive restrictions on the use of drugs, retail prices of drugs, diagnostic and treatment items corresponding to the wrong, account discrepancies and other issues, involving the health insurance fund of 1,731,300 yuan. The local health insurance department in accordance with the "2020 Liaoyuan City health insurance designated medical institutions medical service agreement" Article 64, Article 65, made the following treatment: 1. Recover the illegal use of health insurance fund 173.13 million yuan; 2. Suspension of health insurance services for three months; 3. Deduction of the health insurance physician Liang Mouli, Qin Moying all the annual health insurance physician points, suspend the qualification of health insurance physician for one year.

xiii, Tonghua Shengjing gastroenterology hospital violations

After investigation, Tonghua Shengjing gastroenterology hospital there are low-standard, no indication of hospitalization and other issues, involving the health insurance fund of 3012,000 yuan. The local health insurance department in accordance with the "2021 Tonghua City medical insurance designated medical institutions service agreement" to make the following treatment: 1. order the hospital on the inspection of the problems found in the immediate rectification; 2. recovery of illegal use of health insurance fund 3012,000 yuan; 3. suspension of the hospital's health insurance services for six months; 4. violation of the situation into the annual assessment.

14, Ji'an City, Asia-Pacific Hospital violations

After investigation, Ji'an City, Asia-Pacific Hospital, there are hanging bed hospitalization, low indications of admission, ultra-limited scope of medication, no indications of the use of medication, repeated use of medication, over-treatment, excessive examination and other issues, involving the health insurance fund of 15.74 million yuan. The local medical insurance department in accordance with the "Ji'an basic medical insurance designated medical institution service agreement" "Jilin province medical insurance designated medical institution medical insurance service physician management approach" provisions to deal with the following: 1. order rectification; 2. recovery of illegal use of medical insurance fund 157,400 yuan; 3. suspension of the medical insurance physician LiuMouPeng medical insurance physician qualification, deduct medical insurance physician LiMouFeng, JinMouLu, LvMouHua, PangMou, etc. annual assessment score of 3 points. Annual assessment score 3 points.

fifteen, Liuhe County Central Hospital irregularities

investigated, Liuhe County Central Hospital, there are unreasonable charges, ultra-limited scope of medication, crosstalk project, excessive medical care, false charges, double charges, no indication of medication and other issues, involving health insurance fund 35.88 million yuan. The local health insurance department in accordance with the provisions of the "service agreement" to deal with the following: 1. Ordered to rectify within a certain period of time; 2. Recovered the illegal use of health insurance fund 358,800 yuan; 3. Deducted the health insurance physician Pei Mou, Zhang Mouze and other 33 annual assessment points 2 points; 4. Will be included in the annual assessment of the breach of contract.

sixteen, Jilin Province, Bayshore Hexing health pharmacy chain limited liability company center store, six store violations

investigation, Jilin Province, Bayshore Hexing health pharmacy chain limited liability company center store, six store there is a series of exchange of medicines, the two organizations involved in the health insurance fund *** 92.58 million yuan. The local health insurance department in accordance with the provisions of the "service agreement" to deal with the following: 1. recovery of illegal use of health insurance funds 92.58 million yuan; 2. lifting the designated retail pharmacy service agreement.

XVII, Bayshankangda Pharmacy Chain Co., Ltd. a store violation case

investigated, Bayshankangda Pharmacy Chain Co., Ltd. a store there is a series of drug exchange problems, involving the health insurance fund of 21.9 million yuan. The local health insurance department in accordance with the provisions of the Service Agreement to deal with the following: 1. recovery of illegal use of health insurance funds 21.9 million yuan; 2. lifting the designated retail pharmacy service agreement. The local health insurance department according to the "service agreement" provisions to deal with the following: 1. refused to pay the illegal use of health insurance fund 30,200 yuan; 2. interview the person in charge of the hospital, ordered to rectify the deadline.

xix, Ningjiang Yingxin Hospital violation case

After investigation, Ningjiang Yingxin Hospital, the existence of ultra-limited scope of medication, low indications for admission and other issues, involving 245,300 yuan of health insurance fund. The local medical insurance department, according to the "2020 Songyuan City basic medical insurance designated medical institution service agreement" Article 66, Article 67, made the following treatment: 1. recover the illegal use of medical insurance fund 245,300 yuan; 2. suspension of medical insurance services for two months; 3. rectification of a limited period of time. Because the hospital did not return the illegal health insurance fund to the Songyuan City Social Medical Insurance Administration fund account, the local health insurance department based on the "service agreement" to terminate the hospital health insurance service agreement, and shall not apply for health insurance designated medical institutions within 3 years, and to the people's court of Ningjiang District to apply for compulsory execution.

XX, Changling County, Taipingchuan Town, Xinnuo Pharmacy violations

investigated, Changling County, Taipingchuan Town, Xinnuo Pharmacy did not establish the purchase and sale of inventory ledgers, the store did not have a sales system and other issues. The local health insurance department based on the "2021 Songyuan City medical insurance designated retail pharmacy service agreement" Article 14, Article 24, Article 41 provisions, the following treatment: lifting the designated retail pharmacy health insurance service agreement.

XXI, Zhenlai County Boai Hospital violation case

After investigation, Zhenlai County Boai Hospital there is the use of drugs and diagnostic and therapeutic items in excess of the scope of the problem, involving the health insurance fund of 7.20 million yuan. The local health insurance department in accordance with the "2020 Zhenlai County health insurance designated medical institutions service agreement" 83 provisions, to make the following treatment: 1. interview the person in charge of the hospital, and ordered to rectify the deadline; 2. refused to pay the illegal use of health insurance fund of 7.2 million yuan.

Twenty-two, the first people's hospital in Da'an City, violation of the case

After investigation, the first people's hospital in Da'an City, there is a problem of ultra-limited use of medication, involving the health insurance fund 75,300 yuan. The local health insurance department in accordance with the "2020 Duanan City health insurance designated medical institutions service agreement" Article 83, made the following treatment: 1. Ordered to rectify within a certain period of time; 2. Refused to pay the illegal use of health insurance fund 75,300 yuan.

Twenty-three, Jilin Hua Xi Medicine Chain Co., Ltd. Zhenxing Pharmacy four irregularities

investigated, Jilin Hua Xi Medicine Chain Co., Ltd. Zhenxing Pharmacy four pharmacists are not on duty, part of the drugs are not marked price, not according to the requirements of the uploading of health insurance data, drug purchases and sales of inventory does not match the account, the series of drugs and so on, involving the health insurance fund 1859.80 yuan. The local health insurance department in accordance with the "Yanbian state medical insurance designated retail pharmacy service agreement (2021 version)" provisions to deal with the following: 1. Recovery of illegal use of health insurance fund 1859.80 yuan, recovery of liquidated damages of 557.94 yuan; 2. dissolution of the health insurance service agreement.

Twenty-four, Jilin Pharmacy Pharmaceutical Co., Ltd. Yanji City, Changbaishan Road store violations

investigated, Jilin Pharmacy Pharmaceutical Co., Ltd. Yanji City, Changbaishan Road store there is a string of drugs, involving the health insurance fund 444.70 yuan. The local health insurance department in accordance with the "2021 Yanji City medical insurance designated retail pharmacy service agreement," the provisions of the following treatment: 1. Recover the illegal use of health insurance fund 444.70 yuan, recovery of liquidated damages of 133.41 yuan; 2. Deduction of the second half of the assessment score of 11 points in 2021; 3. Dismissal of the health insurance service agreement.

Twenty-five, Tumen City, the participant Fei Mouzhen violation case

investigation, Tumen City, the participant Fei Mouzhen (deceased) there are duplication of insurance reimbursement issues, involving health insurance fund 5744.21 yuan. The local health insurance department in accordance with the provisions of the "Chinese people's **** and the State Social Insurance Law", made the following treatment: recovery of irregular use of health insurance fund 5744.21 yuan. The local health insurance department brought a lawsuit to the local people's court because the children refused to return the illegal health insurance fund. The local court ruled that the children of the parties concerned should return to the local health insurance department the 5,744.21 yuan of health insurance fund used in violation of the law. At present, the children have been reimbursed the full amount of illegal health insurance funds returned to the Tumen City health insurance fund expenditure account.

26, Meikou Tianbao Neurological Specialty Hospital violation case

After investigation, Meikou Tianbao Neurological Specialty Hospital there is a decomposition of hospitalization, ultra-limited medication, the number of treatments does not correspond to the list of overpayment, the time of psychotherapy does not correspond to the price standard, the list of overpayment does not correspond to the doctor's orders, electroacupuncture treatment and medical records written irregularities and other 6 types of problems, involving health insurance fund 23.14 million yuan. The local health insurance department in accordance with the "Meihekou city medical insurance designated medical institution service agreement text (2021 version)" chapter 7, article 60, paragraph 1, paragraph 3 of the relevant provisions of the hospital to deal with the following: 1. Recovery of irregularities in the use of health insurance fund 231,400 yuan; 2. Order the hospital to immediately rectify.