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big data supervision of medical insurance makes it possible to expose common problems of illegal use of medical insurance funds, such as diagnosis and medication not matching the patient's gender.

on the 31st, the official weibo account of the national healthcare security administration published an article titled "who is providing gynecological treatment to male patients?", exposing 30 medical institutions that rank high in providing gynecological treatment to men and 30 doctors who rank high in prescribing gynecological treatment to men.

the national healthcare security administration stated that local healthcare security departments, in accordance with unified deployment, checked each clue of big data issues issued by the national healthcare security administration, and discovered related violations by a number of medical institutions and hospitals. the next step will be to further expand the screening scope to ensure that all abnormal gender settlement issues in the region are cleared up.

"hysteroscopy", "cervical cancer screening" and "cervical dilation" are all gynecological treatment items, but some male patients have also incurred such medical insurance expenses. from the exposed list, public medical institutions account for the majority, including many central hospitals, people's hospitals, maternal and child health hospitals and township health centers. among them, leiyang people's hospital in hengyang, hunan, conducted 1,674 of the above-mentioned types of illegal inspections in one year.

according to the official website of leiyang people's hospital, the hospital is a tertiary comprehensive hospital integrating medical treatment, emergency treatment, health care, scientific research and teaching. it is the regional medical center of hengyang city. it has successively won the titles of "national people's demonstration hospital", "hunan province civilized unit", and "hunan province advanced medical practice unit".

diagnosis, treatment items, and medication that are inconsistent with gender are a common medical insurance violation, which includes male patients undergoing female-type examinations, females using male items, female patients undergoing male-type examinations, and also prescribing male (gynecological) medications to female (male) patients, etc.

the above article mentioned that some medical institutions switched items to defraud medical insurance when providing gynecological treatment to male patients. these behaviors caused a large number of male patients to incur gynecological treatment expenses by changing self-paid items that were not reimbursed by medical insurance to gynecological reimbursable items. the reason why the hospital did this was to defraud medical insurance.

there are also cases where medical staff allow female patients to use the qualifications of male insured persons to seek medical treatment. after conducting gynecological examinations on women, they allow patients to use the medical insurance certificates of their male relatives to settle the expenses.

local medical insurance departments have also repeatedly exposed this type of insurance fraud. in august last year, the jiangxi provincial medical insurance bureau announced several cases of violations in the use of diagnosis and treatment items that were inconsistent with gender. in may this year, the medical insurance department of xing'an league in inner mongolia reported that gynecological drugs such as "gynecological qianjin tablets" and "fuyankang soft capsules" were reimbursed for outpatient care by male insured persons.

in august this year, many medical institutions including zichang people's hospital in shaanxi province had the illegal practice of men using women's drugs, and included medical insurance expenses that were not covered by the medical insurance fund into the medical insurance fund settlement. the zichang medical insurance bureau took administrative penalties such as interviews, orders to return the illegal medical insurance funds, and fines.

the use of big data in medical insurance supervision has accelerated the exposure of such violations. after the patient settlement fees are uploaded to the medical insurance supervision department, it is easy to discover the hospital's violations through big data analysis.

gao qiumin, associate professor at the school of business of china university of political science and law, told caixin that empowering medical insurance supervision through technologies such as big data will help solve problems such as a wide scope of supervision, heavy workload and insufficient supervisory staff.

recently, the national healthcare security administration exposed an insurance fraud case discovered during a spot check. the suspicious clues were discovered when big data models were used in advance to screen the medical insurance fund usage data in the inspected cities.

starting from 2022, the national healthcare security administration has established an anti-fraud data monitoring zone based on the national unified medical insurance information platform, and has researched and developed big data models such as "false hospitalization", "medical insurance drug reselling", "medical insurance electronic certificate cashing", and "key drug monitoring and analysis". in 2023, it selected multiple cities across the country to carry out the "national anti-fraud big data application supervision pilot" work.

guo jinhui