A group of health hospitals, village doctors were informed! Watch out for these seven things at the end of the year

Medical Network December 15 - The typical case of special governance of the medical insurance fund exposed 23 village doctors illegally reimbursed medical insurance expenses of 1.1962 million yuan on December 11, Sichuan Province, Zigong City held a special health insurance fund governance press conference, to inform the 16 typical cases seized this year, involving a number of health hospitals and a group of rural doctors.
Primary Physicians Commune selected the focus of the case rearranged as follows: Case 1: Fushun County Fushan Town Village Doctors illegal reimbursement of medical insurance fund case in July 2020, Zigong City Medical Security Bureau through big data analysis found Fushun County Fushan Town Health Hospital residents outpatient cost growth abnormal problem clues.
After investigation and verification by the relevant departments found that the town's village health room in the reimbursement of residents' medical insurance outpatient co-ordination, there are over-reporting, year-end centralized surprise reimbursement and non-proportional reimbursement and other issues, 23 rural doctors have not been prorated reimbursement and false reporting of outpatient expenses.
interviewed, he took the initiative to clear up the problem and hand over the funds of 1.1962 million yuan.
Fushan Town Party Committee, discipline committee to eight party members to inform criticism, and three of the village cadres to implement admonishment treatment;
case II: Gongjing District Construction Town Health Hospital unreasonable inspection and treatment of violations of medical insurance agreements, Gongjing District Construction Town Health Hospital in the family planning special family hospital unreasonable inspection, unreasonable treatment and other irregularities.
In accordance with the relevant provisions, the construction of the town health hospital to recover the illegal costs paid 11215.97 yuan, the default payment of 55809.85 yuan, suspended its family planning special family personnel medical insurance network settlement for two months.
case iii: Rong County Lede Center Health Hospital medical insurance violations by big data analysis than the establishment of a file card personnel Yang a certain frequent hospitalization case clues, found that Rong County Lede Center Health Hospital in 2018-2020, there are in-patient signs of lax control, frequent hospitalization, excessive examination and other irregularities.
In accordance with the spirit of the relevant documents and relevant provisions, the hospital made a refusal to pay the basic medical insurance co-ordination violation of the capital of 11143.81 yuan and four times the default payment of 44575.24 yuan, the recovery of major illness insurance reimbursement costs 2226.05 yuan, tilt payment bottom reimbursement 650.83 Yuan, the amount of medical assistance 613.74 yuan to deal with; the county medical security bureau to the director of the hospital, the director and related responsible persons to interview; the clue was handed over to rong county discipline supervision committee in the county health bureau discipline inspection team investigation and treatment; in the county fixed-point medical institutions to inform the Lede Center Health Hospital of excessive medical irregularities, and tasked with comprehensive rectification of the treatment.
case IV: Da'an District Niu Fu Town Health Hospital medical insurance violations in April 2020, Da'an District Medical Security Bureau in the special inspection of the medical insurance fund, found that Da'an District Niu Fu Town Health Hospital unreasonable inspection, unreasonable billing and other medical insurance violations, involving a total amount of medical insurance violations 22735.21 yuan.
the relevant provisions, the hospital was given 22735.21 yuan for refusing to pay the non-compliance capital and 49719.63 yuan for breach of contract.
case five: Zigong City along the beach area along the beach town health hospital medical insurance violations.
In its annual examination and inspection in 2019, the Medical Security Bureau of the Border Beach District found that there were medical insurance irregularities such as disorderly management of patients in hospital, errors in drug-to-code and unreasonable examination, and unreasonable drug use at the Health Hospital along the Beach Town in Zigong City.
in accordance with the relevant provisions, the hospital was given 11049.47 yuan to refuse to pay the violation fee, 69281.41 yuan for breach of contract, the main person in charge of the hospital for interviews, requiring comprehensive rectification of the treatment.
case 6: The medical insurance violation case of wa town center health hospital along the beach area of Zigong City.
In its annual examination and inspection in 2019, the Medical Security Bureau of the Beach District found that there were unreasonable charges, no medical advice charges, decomposition charges and super-standard bed charges and other medical insurance violations in the wa town center health hospital along the beach in Zigong City.
in accordance with the relevant provisions, the hospital was given 7999.41 yuan to refuse to pay the violation fee, 81776.15 yuan for breach of contract, the main person in charge of the hospital to conduct interviews to request comprehensive self-examination and rectification treatment.
the money bag more secure next year to strictly investigate the fraud and insurance behavior in March this year, the State Council promulgated "on deepening the reform of the medical security system."
Article 5 of the "Sound and strong fund supervision system" the third clear: reform and improve the medical insurance fund supervision system, improve the innovative fund supervision methods, according to law to investigate fraud and insurance liability.
, the whole country set off a crackdown on fraud and insurance, and all regions have fulfilled the high standards and strict requirements put forward by the State Council in the areas of institutional reform, innovation in regulatory models and implementation of actions.
according to the spirit of the recent meeting of the State Health Insurance Administration, the National Health Insurance Administration in 2021 will follow the rules and strengthen supervision in accordance with the law, make every effort to build a new pattern of fund supervision, and promote the work to the depth of development.
it is understood that this is the "Health Care Fund Use Supervision and Administration Regulations (Draft)" after the adoption of the health insurance fund management to a more refined direction of development, to combat fraud and insurance efforts to upgrade the beginning.
with the further improvement of relevant laws and regulations, the fight against health insurance funds crime will be upgraded again, so that the cost of fraud insurance again increased.
predictably, next year will be the start of a more stringent model of checking health care funding.
hospitals, deans, down to village health rooms, village doctors, ordinary residents, will be strictly bound.
all primary health care institutions to be vigilant 7 things before the storm again, medical institutions and medical personnel should maintain a high degree of vigilance.
The current forms of supervision are diverse, in addition to the supervision agencies, ordinary people to participate in some areas have been online "electronic eye", with big data to cooperate with the investigation, so do not be lucky psychology.
remember! These seven acts must not be stained.
1. Fictitious medical services, falsifying medical documents and bills, defrauding the Medical Security Fund 2, providing false invoices for insured persons3, including medical expenses that should be borne by individuals in the scope of payment of the Medical Security Fund 4, handling medical security treatment for persons who do not fall within the scope of medical security 5, providing credit card bookkeeping services for non-targeted medical institutions 6, registered hospitalization 7, exchange of drugs, supplies, articles, medical treatment items, etc