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on september 20, the official wechat public account of the national health insurance administration issued a notice that the big data analysis of the administration showed that the hospitalization rate of insured persons in some areas was significantly higher than that in other areas, and the hospitalization rate in some hospitals was abnormally high and extremely abnormal. based on the clues pointed by the big data model, the national health insurance administration, together with the sichuan provincial health insurance department, carried out special unannounced inspections in zigong city, dazhou city and other areas where the hospitalization rate ranked in the top 1/10 in the country.

inspections found that some hospitals used car pick-up and drop-off services, free meals and other means to lure insured persons with no hospitalization indications to falsely hospitalize and defraud insurance. some were hospitalized for nearly 200 days a year, and were hospitalized in the next hospital immediately after being discharged from the previous hospital; some were hospitalized more than 20 times in more than two years; some hospitals did not go through outpatient clinics, and all insured persons were hospitalized regardless of the severity of their illness; some hospitals had only 30 approved beds, but the number of inpatients per day reached 108, far exceeding their service capacity. the medical institutions involved fabricated diagnosis and treatment service items and forged inspection and test reports, resulting in an abnormal increase in regional hospitalization rates and a large amount of medical insurance funds being embezzled and defrauded.

▲photo from the data. photo courtesy of icphoto

a red star news reporter found that the seven medical institutions reported this time were suspected of inducing insured persons to be hospitalized without indication to defraud insurance, suspected of fabricating medical services to defraud insurance, suspected of excessive diagnosis and treatment, ineffective diagnosis and treatment, suspected of forging medical documents, fabricating inspection and testing services to defraud insurance, unqualified personnel suspected of forging medical documents to defraud insurance, suspected of fabricating acupuncture treatment services to defraud insurance, suspected of hanging beds in hospitals to defraud insurance, suspected of fabricating traditional chinese medicine treatment services to defraud insurance, etc.

high frequency of hospitalization

some were hospitalized 16 times a year for 187 days

at fushun west district hospital in zigong city, some inpatients were hospitalized frequently in multiple medical institutions including this hospital. among them, patient zhang was hospitalized 16 times for 187 days in 2023, including 61 days in this hospital, 56 days in zhaohua town health center, and 70 days in gewang nursing home. he often went to another hospital for hospitalization just 2-3 days after being discharged from one hospital.

in addition, the hospital also provides hospital services such as car pick-up and drop-off, free meals and drinks to the elderly in the nursing homes in four townships, zhaohua, gufo, yongnian and banqiao. some people are hospitalized without outpatient treatment, some are admitted immediately after getting off the hospital pick-up vehicle, and some are hospitalized at a fixed time. for example, patient xiao moumou is admitted to the hospital at a fixed time and place on the 23rd of each month.

since 2022, 125 patients admitted to qingkang hospital in qu county, dazhou city, have been hospitalized more than 10 times, most of whom were admitted without outpatient treatment. in the past two years, the hospital has had more than 6,800 inpatients, but only 20 outpatients. during this period, there were 522 days when the number of inpatients exceeded the approved number of beds by 30, 170 days when the number of inpatients exceeded 70, and the highest daily number of inpatients reached 108.

only 5 inspection operations have been carried out

however, more than 5,700 people were charged for inspection

qingkang hospital in qu county, dazhou city is also suspected of forging medical documents and fabricating inspection and testing services to defraud insurance. for example, there were no test reagents, but the corresponding test reports were issued, but the staff actually entered and printed the results manually. for another example, the hospital only purchased one box of c-reactive protein test reagents and only conducted five tests, but charged more than 5,700 test fees.

▲the medical institution involved. photo courtesy of the official wechat account of the national health insurance administration

a similar situation also occurred in zigong mingyang hospital. while carrying out ct scans, they charged for "spiral ct scans" and "x-ray computed tomography (ct) imaging", but did not actually carry out ct imaging. the hospital is also suspected of fraudulently offering micro-acupuncture treatment services to defraud insurance.

it is understood that acupuncture treatment is usually carried out once every 10 days, and each treatment generally does not exceed 2 parts. however, the hospital's rehabilitation department provides treatment for patients once every 3-4 days, and 4 parts each time, which is too high a frequency. upon investigation, it was found that the number of disposable sterile blades charged by the hospital exceeded the purchase quantity, and some patients did not actually receive acupuncture treatment.

78 patients registered as hospitalized

there are only 3 people in the hospital

in addition, zigong mingyang hospital has 70 beds and 130 open beds. in the past two years, a large number of patients were hospitalized in excess of the number of beds, with 1,233 patients being hospitalized in excess of 130 beds. the inspection team found that less than one-third of the patients who registered for hospitalization on the day of the inspection were in the hospital, and most patients signed a discharge notice upon admission.

during the on-site ward rounds at the niufu town central hospital in zigong city on the day of inspection, it was found that among the 78 patients registered as inpatients, only 3 were actually in the hospital, and the majority of patients were not hospitalized for treatment.

it is reported that at present, the local medical insurance department has recovered the losses of the medical insurance fund, suspended the payment of medical insurance expenses to the hospitals involved in the case, initiated administrative penalty procedures, suspended or terminated the medical insurance service agreements of some hospitals, and transferred clues of the problem to the public security, discipline inspection and supervision agencies for disposal.

at the same time, the medical insurance department of sichuan province has stepped up its inspection and crackdown efforts, and further verified that 71 medical institutions have similar problems as mentioned above. it has currently terminated the medical insurance service agreements of 24 institutions, suspended those of 30 institutions, and transferred the illegal clues of 60 institutions to the public security organs.