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wuxi hongqiao hospital was exposed to tampering with ct and mri records, excessive medical treatment and other incidents to defraud medical insurance, which triggered public attention to the issue of insurance fraud by medical institutions.

according to the wechat public account of the national medical insurance administration on september 19 and september 20, according to the big data model clues, the national medical insurance administration, together with the sichuan provincial medical insurance department and the chongqing municipal medical insurance department, carried out special unannounced inspections in the local area.

the wechat public account of the national medical insurance administration announced more than ten cases of violations of laws and regulations. among them, kangning hospital in hechuan district, chongqing clearly stated the price to admit people to the hospital, and paid a referral fee of 300 yuan for each person admitted to the hospital.

1. suspected of inducing patients to be hospitalized to defraud insurance

the hospital is a psychiatric hospital. the hospital regularly issues hospitalization quotas to its employees. the social work department of the hospital contacts residents from nearby streets and towns for hospitalization. the staff receive performance rewards based on the number of hospitalizations they contact. employees of the hospital's social work department, nursing department, and medical insurance information department all receive rewards for introducing others to the hospital.

2. suspected of false hospitalization and insurance fraud

for example, zhou lunshang, a doctor in the first ward of the psychiatric department of the hospital, was hospitalized due to "pulmonary infection" from july 31 to august 3, 2024, incurring hospitalization expenses of 2,597.4 yuan. however, he actually worked the night shift in the hospital on july 31, provided diagnosis and treatment to many patients from august 1 to 2, and was never hospitalized in the hospital at night.

3. suspected of defrauding insurance through fictitious diagnosis and treatment services

the hospital charges a large number of transcranial magnetic stimulation treatment fees for psychiatric patients all year round. since 2022, the hospital has charged 95,000 people. however, an inspection 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 never entered the transcranial magnetic stimulation treatment room. step into the treatment room to receive your treatment. the hospital claims to use an electroencephalogram biofeedback therapy device to carry out biofeedback treatment, but since 2022 there are only 3 treatment records, and the number of charges for this project is actually as high as 96,000.

for example, patients zhang*fang and yang*lin who were frequently hospitalized in this hospital had basically the same color ultrasound reports of their liver, gallbladder, pancreas, spleen and kidneys during their four hospitalizations. another example is that the eye movement examination should be performed by a specialist using an eye movement detector to record the eye movement trajectory, determine the gaze point and response exploration score according to the procedure, analyze the data, determine the results and issue a report, but this hospital is operated and issued by unqualified nursing staff. report.

in addition to chongqing hechuan district kangning hospital, chongqing hechuan kanggu hospital, sichuan north hospital, chongqing kaizhou district huaxin obstetrics and gynecology hospital, jianmin hospital, and minren anorectal hospital also defrauded insurance through various methods. such as using other people's names to make false propaganda, allowing unqualified personnel to forge medical documents, fictitious diagnosis and treatment services, induced hospitalization, packaged medication, practicing medicine without a license, etc.

the chongqing municipal medical insurance department has carried out expanded inspections across the city for similar issues. currently, 52 hospitals have been initially inspected, 7 have been shut down, and 6 have been transferred to the public security organs or jointly investigated with the public security organs.

medical insurance funds are the people's "medical treatment money" and "life-saving money" and are related to the vital interests of every insured person. criminals use various means to transfer funds that should be used for actual patient treatment into the pockets of individuals or institutions. this not only aggravates the strain and waste of medical resources, seriously damages the cornerstone of public interests, and shakes the foundation of trust in the medical insurance system. it also poses a threat to the sustainability of the national medical insurance system and affects the normal operation of the entire medical system.

it is hoped that the hospital can strengthen internal management and improve the professional ethics and professional quality of doctors. doctors should also always keep their mission and responsibilities in mind, put the health and safety of patients first, and not lose their conscience for the sake of money.

written by | anna.an

editor | swagpp