The Chinese Commission for Discipline Inspection will hold a meeting in 2020 to focus on strictly checking these behaviors

Editor: Liu Xiaolin, basic doctors' Commune The plenary session of the Central Commission for Discipline Inspection issued a heavy signal: in 2020, we will resolutely investigate and deal with collusion, fraud and insurance fraud within and outside medical institutions, and establish and strengthen a long-term regulatory mechanism He stressed that we should resolutely investigate and deal with collusion, fraud and insurance fraud inside and outside medical institutions, and establish and strengthen a long-term regulatory mechanism It can be seen that after 2019, the state will continue to fight against deception under high pressure, which is bound to be a long-term war As of June last year, 57000 medical institutions have been investigated and dealt with, including some health centers, village clinics, community health service stations and other basic medical institutions The grassroots doctors' Commune summarized the typical cases reported by the state health insurance bureau last year, hoping you can learn from them Case 1: defrauding medical insurance fund by false hospitalization 207 suspected illegal medical records were found in the Central Hospital of Tulihe Town, Yakeshi City, Hulunbuir City, Inner Mongolia Autonomous Region, and there were violations of agreement management such as over inspection, over diagnosis and over medical treatment Punishment: recover the medical insurance fund of 22000 yuan and impose a five times fine of 110000 yuan The health and family planning department shall make a decision to stop the work of the person in charge of the hospital and deal with the relevant illegal and disciplinary staff Case 2: case of fictitious five guarantee households defrauding medical insurance fund in hospital Lei, the president of the hospital, instructed the doctor to contact the hospital and collect the register of the five guarantees in the name of physical examination In February 2018, 28 five guarantee households, such as Liu and Chen, went through the hospitalization procedures in the form of hanging bed for hospitalization and fictitious expenses, and arranged the staff of the hospital to make false doctor-patient communication records, medical records, diagnosis books, prescriptions and other relevant information, illegally obtained 36000 yuan of medical insurance fund Punishment: shut down the medical insurance reimbursement system of the hospital, suspend the medical insurance service, order comprehensive rectification, recover and collect 36000 yuan of medical insurance fund, refuse to pay the medical insurance fund 5 times of the illegal expenses, and suggest the health and family planning department to deal with the relevant medical personnel of the hospital The discipline inspection and supervision department gave a serious warning to Lei and admonished and talked to six staff members of the hospital Case 3: collusion of drugs to defraud medical insurance fund Li Mou is in charge of the health office and smart drug supermarket in Pudu village, Kaizhou District, Chongqing From February 2018 to November 2018, the health office of this village defrauded 209000 yuan of medical insurance fund by swiping the card to reimburse the smart drug supermarket for drug expenses and exchanging drugs in series Punishment: suspend its medical insurance network settlement for 3 months, suspend the medical insurance doctor qualification of Li for 6 months, recover the illegal fee of 200900 yuan, and impose a double penalty, refuse to pay the village's general diagnosis and treatment fee of 13500 yuan in 2018, and order the smart drug supermarket to rectify within a time limit Case 4: buying patients to defraud medical insurance fund Fuyang Shuanglong hospital, Fuyang City, Anhui Province, defrauded the medical insurance fund by buying patients from rural doctors in the form of payment rebate, over treatment, over inspection, over range practice, independent diagnosis and treatment activities of non-health technical personnel, etc Punishment: recover 563500 yuan of medical insurance fund, and impose a fine of 907500 yuan, terminate the medical insurance service agreement, and transfer the clues of relevant issues to the public security organ for further investigation The hospital was fined 4000 yuan and its practice license was revoked Case 5: purchase of false purchase invoice to defraud medical insurance fund Shiguzhuang community health service station, Songzhuang Town, Tongzhou District, Beijing swindled medical insurance fund by purchasing false purchase invoices and yin-yang prescriptions From January to August 2018, the person in charge of the service station purchased 8 purchase invoices of Chinese herbal pieces from the Internet, cheating medical insurance fund of RMB 602300 Punishment: terminate the medical insurance service agreement Tongzhou branch of Beijing Municipal Public Security Bureau has detained the person in charge of the service station The case is still under further investigation, and the illegal amount will be recovered immediately after verification Case 6: swindle medical insurance fund by changing medical insurance code From July 2017 to June 2018, the Health Institute of longbian, Maxiang Health Hospital, Xiang'an District, Xiamen City, Fujian Province, defrauded 9611000 yuan of medical insurance fund by replacing medical insurance code, carrying out diagnosis and treatment projects beyond the payment scope of medical insurance, etc Punishment: refuse to pay the medical insurance fund of 9611000 yuan; suspend the medical insurance network access of the health center for 6 months; deduct 12 points from the credit of a responsible doctor and refuse to pay the medical insurance service fee for 12 months Case 7: medical insurance fund fraudulently obtained by exchanging diagnosis and treatment projects Lanyang Health Hospital of Lankao County, Henan Province defrauded 2.6683 million yuan of medical insurance fund by means of serial diagnosis and treatment projects and over treatment Punishment: recover 2.6683 million yuan of medical insurance fund, fine 5.3366 million yuan, cancel the medical insurance doctor qualification of Xiao, the main body involved in the case, and remove the medical insurance designated qualification of the department involved in the hospital The health department dismissed the president of the hospital and criticized the hospital in the county Case 8: breaking down charges and other cases of defrauding medical insurance funds In February 2017, Jintian Hospital of Guiping City, Guangxi Zhuang Autonomous Region, defrauded 83800 yuan of medical insurance fund through fictitious medical services, breakdown of fees and other means Punishment: recover the medical insurance fund of 83800 yuan, order it to rectify immediately, at the same time, cooperate with the health department to remove the president of the hospital, and jointly with the Commission for Discipline Inspection and supervision commission to investigate the relevant responsibilities of the illegal personnel of the hospital From the above several typical cases of fraud, we can find that there are various forms of fraud It is reported that this year, one of the seven major tasks of the medical insurance department is to make unremitting efforts to crack down on fraudulent insurance, improve relevant laws and systems, and establish and improve long-term mechanism From the Central Commission for Discipline Inspection to the medical insurance department, we can feel the strength of this year's crackdown on fraud and insurance fraud in medical institutions, which is growing unabated Again, we must not make the following mistakes: ① Fabricate medical services, forge medical documents and bills, and defraud medical security funds; ② Provide false invoices for the insured; ③ The medical expenses that should be borne by the individual shall be included in the payment scope of the medical security fund; ④ To handle medical security treatment for the personnel who do not belong to the scope of medical security; ⑤ Provide credit card bookkeeping services for non designated medical institutions; ⑥ Registered in Hospital; ⑦ To defraud medical security fund expenditure by exchanging drugs, consumables, articles, diagnosis and treatment projects in series; ⑧ Other frauds and frauds committed by designated medical institutions and their staff The service agreement shall be terminated in case of any of the following violations: ① Falsifying medical documents, financial bills or vouchers to defraud medical insurance funds by making up "false hospitalization and false medical treatment" of medical services; ② Providing medical expenses settlement for non designated medical institutions and medical institutions with suspension of agreement; ③ During the validity period of the agreement, it has been suspended for 3 times in total or it has not been rectified as required by the time limit or the rectification is not in place; ④ The medical institution's practice license and business license have been revoked; ⑤ Refusing, obstructing or not cooperating with the agency to carry out necessary supervision and inspection; ⑥ Other violations that cause serious consequences or significant impact.