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wuxi hongqiao hospital was exposed for tampering with ct and mri records, over-treating patients and other methods to obtain medical insurance, which has aroused public concern about the problem of insurance fraud in medical institutions.

the paper noted that many places have recently reported on the illegal use of medical insurance funds by medical institutions in their jurisdictions. many hospitals have been fined for illegal and irregular acts such as hospitalization without indications and suspected falsification of examination and test reports in order to defraud medical insurance funds. there are also medical institutions that have violated regulations such as charging above the standard, excessive examinations, repeated charges, switching charges, and payments beyond the medical insurance limit.

among them, some hospitals used methods such as pick-up and drop-off, free meals, etc. to lure insured persons with no indications for hospitalization to falsely hospitalize and defraud insurance; one health center reused 26 color ultrasound images 608 times, causing the images and report contents of some patients' color ultrasound reports to be exactly the same; one hospital was suspected of using templates to write medical documents, and the diagnosis history, treatment plans and medical records of different patients were highly similar, and it was suspected that the medical records were written using templates.

26 color ultrasound images were reused 608 times

"the national medical insurance administration's big data analysis shows that the hospitalization rate of insured people in some regions is significantly higher than that in other regions, and the hospitalization rate in some hospitals is abnormally high, which is extremely abnormal."

according to articles posted on the national healthcare security administration's official wechat account on september 19 and september 20, based on clues from big data models, the national healthcare security administration, together with the sichuan provincial healthcare security department and the chongqing municipal healthcare security department, carried out special flight inspections in the local area.

the exposed photo of chongqing hechuan district kangning hospital from southern metropolis daily

the national medical insurance administration’s wechat official account has published more than ten cases of illegal and irregular activities. among them, chongqing hechuan district kangning hospital clearly marked a price for hospitalization, paying a referral fee of 300 yuan for each hospitalization. the hospital is suspected of inducing patients to be hospitalized to defraud insurance. the hospital is a psychiatric hospital. the hospital regularly issues hospitalization targets to employees. the hospital’s social work department contacts nearby residents for hospitalization, and staff receive performance rewards based on the number of hospitalizations. employees of the hospital’s social work department, nursing department, and medical insurance information department all receive rewards by referring others for hospitalization; the hospital is suspected of fraudulent insurance by false hospitalization and suspected of fraudulent insurance by fictitious medical services.

in this case, the hospital has been charging a large amount of transcranial magnetic stimulation treatment fees for mental patients all year round, with fees reaching 95,000 since 2022. however, inspections found that in july 2024, only a few patients entered and exited the transcranial magnetic stimulation treatment room, and 84% of the patients who had been charged had never set foot in the treatment room for treatment. the hospital claimed that it used eeg biofeedback therapy equipment to carry out biofeedback treatment, but there were only three treatment records since 2022, while the number of charges for this project was as high as 96,000.

the exposed image of fushun west district hospital in zigong city, sichuan province, from southern metropolis daily

the aforementioned article also disclosed that some inpatients of fushun west district hospital in zigong city, sichuan province were hospitalized frequently in multiple medical institutions including this hospital. for example, patient zhang mouyuan 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 pigeon king nursing home. he was often discharged from one hospital for 2-3 days and then went to another hospital for hospitalization again. the hospital is suspected of inducing insured persons to defraud insurance by hospitalization without indication. the hospital provides hospitalization services such as car pick-up and drop-off, free food and drink, etc. to the elderly in nursing homes in four townships of zhaohua, gufo, yongnian, and banqiao. in addition, it is also suspected of fabricating medical services to defraud insurance, excessive medical treatment, and ineffective medical treatment.

for example, patient wang mingming should be diagnosed with acute exacerbation of chronic bronchitis based on medical history and physical examination, and the attending physician also confirmed that the patient actually suffered from bronchitis. however, without any clinical diagnostic basis, the hospital admitted the patient with chronic obstructive pulmonary disease and prescribed a full set of imaging and biochemical tests. from 2022 to 2023, the proportion of patients admitted to the hospital with chronic obstructive pulmonary disease accounted for 21% of the inpatients in the internal medicine department, and excessive diagnosis and treatment was common.

the aforementioned article mentioned that since 2022, 125 people have been hospitalized more than 10 times at qingkang hospital in qu county, dazhou city, sichuan province, and most of them were admitted without outpatient treatment. the hospital has had more than 6,800 inpatients in the past two years, but only 20 outpatients. in the past two years, there were 522 days when the number of inpatients exceeded 30 approved beds, 170 days when the number of inpatients exceeded 70, and the highest daily number of inpatients reached 108.

qingkang hospital is suspected of inducing insured persons to be hospitalized without indications to defraud insurance. the hospital's driver zhang huajun went to nearby villages and towns to persuade residents to be hospitalized, and the hospital issued performance rewards on a monthly basis based on the number of patients admitted. the hospital waived out-of-pocket expenses for inpatients and induced insured persons to be admitted without indications. for example, a large number of patients were admitted with normal body temperature and normal blood test results, without any evidence of acute infection, but were all admitted for acute exacerbation of chronic obstructive pneumonia and various types of acute infections.

qingkang hospital is also suspected of forging medical documents and fabricating inspection and testing services to defraud insurance. for example, there were no inspection reagents, but the corresponding inspection reports were issued, but the staff actually entered and printed the results manually. another example is that only one box of c-reactive protein detection reagent was purchased, and only 5 inspection operations were carried out, but more than 5,700 inspection fees were collected. third, unqualified personnel are suspected of forging medical documents to defraud insurance. for example, unqualified personnel luo xiao forged the signature of doctor fang * xu to issue a b-ultrasound inspection report, and unqualified personnel jiang hai forged the signature of doctor chen * qin to issue a stool routine and urine analysis report.

the hospitals reported above also include mingyang hospital in zigong city, sichuan, niufo town central hospital in zigong city, sichuan, sanban town hospital in qu county, dazhou city, sichuan, wanshou town hospital in qu county, dazhou city, sichuan, and wanyuan jian'an hospital in dazhou city. it was mentioned that wanshou town hospital in qu county, dazhou city, sichuan reused 26 color ultrasound images 608 times, causing the images and report contents used in the color ultrasound reports of some patients to be exactly the same; the rehabilitation department of niufo town central hospital in zigong city, sichuan, still recorded and carried out electroacupuncture, acupuncture point massage with medicine sticks, chinese medicine stains, medium-frequency pulse electrotherapy and other projects during the rest days when the doctors were not at work, suspected of fictitious diagnosis and treatment services.

in the above cases, many hospitals were suspected of cheating insurance by using hospital beds. among them, the mingyang hospital in zigong city, sichuan province, had 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. on-site inspections 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 notice of discharge upon admission.

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

the medical history, diagnosis and treatment plans of different patients are highly similar

in addition to the national healthcare security administration’s report on medical institutions’ illegal use of medical insurance funds, medical insurance bureaus in many places have also recently made public related cases.

on september 20, the wechat public account "guangdong medical insurance" reported several cases of illegal use of medical insurance funds. among them, shenzhen renkang hospital had illegal and irregular behaviors such as repeated charges and substitution of medical treatment items, involving 184,086 yuan of medical insurance funds. in accordance with the relevant provisions of the "regulations on the supervision and administration of the use of medical insurance funds", the local medical insurance department made the following decisions: 1. order the parties to make immediate corrections; 2. return the 184,086 yuan of medical insurance funds used illegally; 3. fine 184,086 yuan; 4. interview with the person in charge of the hospital.

in addition, based on clues from special inspections, the medical insurance bureau of jiaoling county, meizhou city, found that jiaoling minkang hospital had conducted illegal and irregular activities such as conducting the "extrapyramidal side effect scale" and "auricular acupoint pressure beans" projects on some patients without indications, and using "enteral nutrition suspension (tpf) and omeprazole sodium" without indications in patients, involving 287,917.3 yuan of medical insurance funds.

on september 21, the wechat public account "hotan medical insurance" reported that big data analysis showed that the hospitalization rate in some medical institutions was significantly higher than in other regions, which was extremely abnormal.

among them, unqualified personnel in yutian hope hospital in hotan prefecture are suspected of forging medical documents to defraud insurance. unqualified personnel in the hospital are suspected of forging the signatures of imaging physicians to issue x-ray photography, ultrasound, electrocardiogram, and dynamic electrocardiogram reports; the hospital's laboratory department has no laboratory qualifications, but is engaged in laboratory work and issues laboratory reports; and is suspected of using templates to write medical documents. the medical history diagnosis, treatment plan, and medical records of different patients are highly similar, and it is suspected that the medical records are written using templates. third, there is no indication for hospitalization for related treatment and fictitious diagnosis. fourth, there are violations such as over-standard charges, excessive examinations, and payments beyond the medical insurance limit. fifth, the hospital management is chaotic. the management of purchase, sales, and inventory is chaotic, and package inspections have caused losses to the medical insurance fund. at present, the hospital has suspended medical insurance services, and the medical insurance department will handle it in accordance with the law and regulations and recover illegal and irregular funds.

the aforementioned notice also mentioned that after analyzing the 2024 hospitalization data of shennong deyi traditional chinese medicine hospital in hotan city, hotan prefecture, it was found that there was an abnormal increase in medical expenses data. through an on-site inspection of the hospital, it was found that the hospital was suspected of charging in pairs, unindicated tests, over-standard charges, decomposed charges, and physical therapy projects without a physical therapy registration ledger (specific data is being verified). there is a risk of causing significant losses to the medical insurance fund and suspected of insurance fraud. the medical insurance settlement service has been terminated for the hospital.

the wechat public account "xinjiang medical insurance" announced on september 25 that it is now reporting 12 typical cases of illegal use of medical insurance funds.

among them, turpan people's hospital had problems such as over-standard charges, including items that were not covered by medical insurance into the medical insurance fund settlement, excessive medical treatment, repeated charges, and interchangeable charges. it was ordered to rectify within a time limit, recover 827,895.71 yuan of illegal medical insurance fees, impose an administrative fine of 1,159,053.99 yuan, and interview the relevant persons in charge. in addition, more than a dozen clinics or companies, including yu zeying tongtai clinic in gaochang district, had problems such as over-standard charges, including items that were not covered by medical insurance into the medical insurance fund settlement, and excessive medical treatment.