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according to the national medical insurance bureau, big data analysis shows that the hospitalization rate of insured people in some areas is significantly higher than that in other areas, and the hospitalization rate in some hospitals is extremely high, which is extremely abnormal.

according to the clues of the big data model, the national medical insurance administration, together with the guangxi medical insurance department, carried out unannounced inspections of nanning, qinzhou and other cities. the inspection found that

patients who were hospitalized multiple times within a short period of time had inconsistent records of their illness.the gender changes from male to female, and the patient’s signature and handwriting are inconsistent;

the height is sometimes high and sometimes short,he was 167cm when he was hospitalized for the first time, and became 152cm when he was hospitalized again;

hemiplegic limbs fluctuate from left to right,one hospitalization was on the left side, and another hospitalization on the right side was suspected of false hospitalization and false diagnosis and treatment.

these problems have led to an abnormal increase in regional hospitalization rates, and a large amount of medical insurance funds have been defrauded. some cases are now announced as follows:

national medical insurance administration announces multiple warning cases

shanglin xiaorenhe traditional chinese medicine hospital, nanning city, guangxi.

the hospital has a clearly stated price to admit people to the hospital, and will be rewarded with a referral fee of 180 yuan for each person admitted to the hospital.

1. suspected of forging medical records and defrauding insurance companies. like the same patient being hospitalized twice,the gender in the disease course record is sometimes male or female, and the patient's signature is inconsistent in handwriting;for patients who were hospitalized three times in a short period of time, their condition was recorded as right hemiplegia twice and left hemiplegia once.

2. unqualified personnel are suspected of forging image reports to defraud insurance companies. tan qiwen, an imaging medical technician at the hospital, has been away from work for a long time and is paid for "certification". on a daily basis, unqualified personnel lan yunqiu and others conducted radiology, ultrasound, electrocardiogram and other diagnosis and treatment, and forged tan qiwen's signature to issue reports.

3. suspected of inducing insured persons to be hospitalized without indications to defraud insurance. the external relations department of the hospital solicits and induces insured persons to be hospitalized by promising free hospitalization, car pick-up and drop-off, etc., and will receive performance rewards based on the number of hospital admissions attracted. most patients are admitted directly to the hospital without outpatient evaluation.

shanglin xiaorenhe hospital of traditional chinese medicine, nanning city, guangxi

fusheng nursing home, qinzhou city, guangxi.

1. suspected of fictitious imaging examination service fraud and insurance fraud. for example, patients li *he, huang *quan, and ruan *ping did not have chest x-ray imaging data during their hospitalization. chu*jia, luo *lian, and zhao *qin did not have color ultrasound imaging data during their hospitalization, but the hospital charged corresponding examination fees.

2. suspected of fictitious inspection service fraud and insurance fraud.

3. suspected of fictitious diagnosis and treatment services and insurance fraud. the hospital's treatment records show that patients with sores were given patching therapy, but inspection found that the patients had no sores, there were no patching drugs in the treatment room, and there were no traces of treatment on site.

4. suspected of fraud and insurance fraud by forging medical records. multiple patients were hospitalized at the same time, and their admission diagnoses, medical history and signs, disease course records, medical orders, etc. were highly similar.

fusheng nursing home, qinzhou city, guangxi

haiwan nursing home, qinzhou city, guangxi.

1. suspected of false hospitalization fraud and insurance fraud. some of the hospital's inpatients are elderly residents supported by the hong maple leaf nursing home (nursing home) at the same location. the inspection found that while some elderly people were receiving care in the nursing home, diagnosis and treatment records were generated and billed in the nursing home.

2. suspected of fictitious inspection service fraud and insurance fraud.

3. suspected of fictitious imaging examination service fraud and insurance fraud. the hospital had some anomalies such as charging for x-rays without performing them, and reporting them in the medical records despite no records in the imaging system.

4. unqualified personnel are suspected of practicing medicine without a license and committing insurance fraud.

guangxi qinzhou bay bay nursing home

huakang hospital, hengzhou city, guangxi.

1. suspected of forging medical records and defrauding insurance companies.the same patient was admitted to the hospital more than a month apart. his height was 167 cm when he was admitted to the hospital for the first time, and he was 152 cm when he was admitted again.

2. suspected of forging inspection reports and fabricating inspection services to defraud insurance companies. the imaging examination time of some patients is later than the discharge time. for example, patient zhang* had his examination time on march 27, but he was discharged from the hospital on march 26.

3. suspected of fictitious inspection service fraud and insurance fraud. during the inspection period, the hospital conducted routine actual inspections for 150 people, but applied for medical insurance to pay for routine stool examinations for 1,073 people.

huakang hospital, hengzhou city, guangxi

renkang hospital, qinzhou city, guangxi.

suspected of fictitious medical service project fraud and insurance fraud. from 2022 to 2023, the hospital purchased a total of 1,400 consumable slides necessary for routine stool examination, but charged 2,127 routine stool examination fees; it purchased 177,100 acupuncture needles, but applied for medical insurance settlement for 227,300.

renkang hospital, qinzhou city, guangxi

for the above-mentioned designated medical institutions, the guangxi medical insurance department has taken measures such as recovering losses from medical insurance funds, suspending the payment of medical insurance fees, initiating administrative penalty procedures, suspending or canceling medical insurance service agreements, etc.;for the doctors involved in the case, management measures such as canceling medical insurance service qualifications and deducting points for breach of trust were adopted; at the same time, relevant clues were transferred to the public security, health, market supervision and other departments for disposal. the public security organs have launched investigations into some institutions.

2

relevant personnel of designated medical institutions violate laws and regulations

may be terminated from medical insurance payment qualifications

today (27th), the national medical insurance administration held a press conference on the "guiding opinions on establishing a medical insurance payment qualification management system for relevant personnel in designated medical institutions". the objects of medical insurance supervision will extend from institutions to relevant personnel. the medical insurance payment qualification management system for relevant personnel of designated medical institutions is under the framework of medical insurance agreement management.starting from the key link of medical insurance payment, "driver's license-style scoring" will be implemented for relevant personnel of designated medical institutions to achieve dynamic and refined management.

according to the relevant person in charge of the national medical insurance administration, according to the service agreement signed between the designated medical institution and the medical insurance agency, relevant personnel involved in the use of medical insurance funds at this designated medical institution are eligible for medical insurance payment, and are also included in the scope of medical insurance supervision. mainly includes two categories:

the first category is hospital-related personnel, including medical, nursing, and technical health professionals who provide services to insured persons, as well as relevant staff responsible for medical expenses and medical insurance settlement review.

the second category is the main person in charge of the designated retail pharmacy, that is, the main person in charge on the drug business license.

relevant personnel are deducted 12 points in a calendar year

eligibility for medical insurance payment will be terminated

in the supervision of the medical insurance department, if relevant personnel are found to have violated laws and regulations, they will be scored according to the severity of the problem:

relatively minor ones will be scored with 1 to 3 points, more serious ones will be scored with 4 to 6 points, more serious ones will be scored with 7 to 9 points, and the most serious fraud and insurance fraud will be scored with 10 to 12 points.

if the score reaches 9 points in a calendar year, the medical insurance payment qualification will be suspended for 1 to 6 months, and the medical insurance expenses incurred for services provided during the suspension period will not be settled (except for first aid and rescue).

if the score reaches 12 points in a calendar year, the medical insurance payment qualification will be terminated, and the medical insurance expenses incurred for services provided during the termination period will not be settled. among them, if a total of 12 points is accumulated, the registration shall not be filed again within one year from the date of termination; if a total of 12 points are accumulated, the registration shall not be registered again within 3 years from the date of termination.

national network linkage for score processing and corresponding measures

coupled with the linkage of the three medical institutions to form a joint regulatory force

once the medical insurance payment qualification is suspended or terminated at a designated medical institution, corresponding measures will also be taken at other designated medical institutions. if scores are processed in one region, the information will be shared across the country to achieve cross-agency and cross-regional linkage.

the relevant person in charge of the national medical insurance administration introduced that the medical insurance payment qualification management system is an important starting point to strengthen the linkage and collaborative governance of medical insurance, medical care, and medicine. the medical insurance department will notify the health department and the drug regulatory department of the relevant information about points, suspensions and terminations, and they will strengthen the management of relevant personnel in accordance with their responsibilities and jointly form a joint regulatory force.

"one person, one file" comprehensively records compliance with laws and regulations related to medical insurance

the medical insurance department will establish a "one person, one file" medical insurance integrity file for relevant personnel of designated medical institutions.

everyone will receive a lifetime unique identity code like an id card, which does not change with the household registration address or residential address.

each person will also have his or her own medical insurance integrity file, which comprehensively records his or her scorekeeping and other compliance with medical insurance-related laws and regulations, accompanying them throughout their career.