2020-12-08

Primary medical institutions frequently issue violations of regulations, strictly investigate public officials participating in fraudulent insurance

By yqqlm yqqlm

Strictly investigate the participation of public officials in fraudulent insurance

Basic medical institutions are prone to violations of regulations. The medical insurance supervision department has low efficiency in reviewing clues and excessive penalties. In response to these problems, Huai’an City, Jiangsu Province The Commission for Discipline Inspection and Supervision adopted project supervision, special supervision and other methods to establish four mechanisms of essential information notification, joint inspection, clue transfer, and joint punishment, to severely punish the corruption behind fraud and insurance, and effectively safeguard the vital interests of the people.

  1. In response to medical institutions’ violations of regulations, more phenomena are found –

Increase penalties and form continuous deterrence

“Huaiyin District Xisongji Health Center violates regulations Lowering the admission standards for patients, suspected of defrauding medical insurance expenses, giving the former president Jiang Qikun (later the president of the Guzhai Health Center) serious party warnings, administrative sanctions, and removal of the president of the Guzhai Health Center…” Recently, The Huai’an Disciplinary Commission and Supervisory Committee has continuously notified and handled many typical cases involving public officials in Huaiyin District, Huai’an District, Lianshui County, Qingjiang Pu District and other places involving fraud and insurance, involving a total amount of 2.277 million yuan.

“The clues to these cases were transferred by the Medical Insurance Bureau. We conducted an in-depth investigation based on the clues and found that the Xisongji Health Center had admitted 8 five-guarantee elderly people and were admitted and discharged repeatedly within 15 days of the same disease , Disintegrate hospitalization, and even individual patients have repeated admissions and exits for 45 times in 2 years, which obviously exceeds the scope of reasonable and necessary medical services, and is suspected of defrauding medical insurance expenses of more than 700,000 yuan.” According to the case handler of the Huaiyin District Commission for Discipline Inspection, the investigation found that some primary medical institutions There are many tricks of fraudulent insurance, such as lowering the admission standard and breaking down the admission. For example, the Yixing Township Health Center in Lianshui County used methods such as tearing up the inspection date, tampering with inspection results, scraping the diagnosis opinion, digging the inspection sample number, deliberately folding the inspection sheet and sticking it with glue, etc., to damage, destroy, and tamper with the medical records. To achieve the purpose of illegal withdrawal of medical insurance funds.

In this regard, the Huai’an Commission for Discipline Inspection has established a project to supervise and promote special management of problems in the field of medical insurance funds. On the one hand, we firmly grasp the leading department of the Medical Insurance Bureau, urge it to take the responsibility of the main body of business supervision, seriously investigate and deal with the problem of insurance fraud by medical institutions, and promptly transfer clues to the discipline inspection and supervision organs of the same level that involve party members and cadres and supervision objects. . On the other hand, the establishment of a comprehensive supervision network that is coordinated by the supervision department, dispatched to the disciplinary inspection and supervision team to accurately embed, the county and district disciplinary commissions to conduct direct inspections and quickly handles, and the disciplinary inspection and supervision agencies set up in public medical institutions to closely cooperate with the people. Complicated cases are listed for supervision, and the cities and counties jointly handle difficult cases.

Since this year, the Huaian Municipal Commission for Discipline Inspection has listed and supervised the handling of 5 key cases. Among them, in response to the fraud and insurance problems of the hand-foot microsurgery diagnosis and treatment team assigned by the National Medical Security Administration, the Supervision and Inspection Office of the Municipal Commission for Discipline Inspection and the county and district Commission for Discipline Inspection intervened in advance to identify violations and identify personnel qualifications Several rounds of conferences and chambers were organized. In the end, 22 public officials were held accountable, and more than 1.5 million yuan of illegal funds were recovered.

“Since this year, the discipline inspection and supervision agencies at all levels in the city have investigated 28 cases of violations of discipline and law in the medical insurance field, 31 people have been punished by party discipline and government affairs, and supervision departments have been urged to deal with 1,152 illegal medical institutions, involving 79.309 million yuan of illegal funds. “The relevant person in charge of the Huai’an Discipline Inspection Commission said.

  1. Aiming at the weak links that are prone to rent-seeking——

Online and offline integration, strengthen daily supervision

“In February of this year, Bori Health Center There were 12 early warnings that month. Please find out the cause immediately by your bureau and the health department.” Not long ago, the Huai’an District Commission for Discipline Inspection of Huai’an City found the problem through online supervision and immediately urged the supervision department to perform the main responsibility.

“After investigation, the health center has violations such as out-of-scope diagnosis and treatment, bed hanging hospitalization. Due to the minor circumstances, our bureau has notified the health department to interview the director of the hospital and deduct violations Expenses.” Three days later, the Huai’an District Medical Insurance Bureau reported the results to the District Commission for Discipline Inspection.

Previously, the Huai’an Commission for Discipline Inspection found that during the supervision of the medical security fund field, the daily supervision of the Huai’an Medical Insurance Fund still focuses on manual inspection of medical records, which is not only inefficient, but also extremely easy Generate profit-seeking space. To this end, the Huai’an Municipal Commission for Discipline Inspection took special supervision as a starting point, conducted in-depth visits and investigations in public medical institutions, gradually figured out the relevant procedures and key links of diagnosis and treatment services, medical insurance reimbursement, and urged the Medical Insurance Bureau to establish disease categories based on 2501 diseases in Huai’an. The diagnosis and treatment model is used to screen out the key indicators such as hospitalization expenses, length of stay, project violations, and suspicious points to set early warning scores, and embed the “Supervision of Discipline Inspection Commission” module in the municipal medical insurance supervision platform, and carry out online automatic early warning at different levels. , The second-level early warning is sent to the medical insurance department for verification, and the third-level early warning is sent to the Commission for Discipline Inspection and Supervision to follow up and supervise and further verify whether there are violations of discipline or law.

The setting of hierarchical early warning allows every clue of medical preservation suspected problems in the city to be exposed to the “sunlight”. The details of all clues and processing progress are all displayed online, traces are kept throughout the process, the results are disclosed, and clues to medical insurance problems The Commission for Discipline Inspection and Supervisory Committee can trace back and investigate the responsibilities online at any time.

In addition to online normalization of supervision, the Huai’an Municipal Commission for Discipline Inspection selects one work focus every quarter to carry out special supervision. The first three quarters of this year are focused on the innovation and promotion of medical insurance fund supervision methods, recovery of illegal funds, and early warning Special supervision was carried out on issues such as follow-up and disposal, and more than 40 various issues were assigned on the spot.

“In the past, the medical insurance system had greater discretion in law enforcement and supervision. With the continuous strengthening of the supervision of the Commission for Discipline Inspection and Supervision, we are forced to investigate all violations of laws and regulations. Work efficiency and integrity put forward higher requirements.” said Yin Yaqin, director of the Huai’an Medical Insurance Bureau.

  1. In response to the problem of poor information exchange between departments –

Promote the establishment of a joint management and long-term supervision mechanism

“The Party Committee of the Health Commission emphasizes performance Light management, basic health center salary performance bonus is based on diagnosis and treatment business income, lack of education and management mechanism for the head of the primary health center and its medical technicians, not paying attention to medical ethics and medical style education, and lax management of assessment and management of insured personnel , There are loopholes in the internal control mechanism.”

The Commission for Discipline Inspection of Lianshui County, Huaian City recently issued a disciplinary inspection recommendation to the county health and health commission. In response to the frequent occurrence of illegal insurance fraud, excessive medical treatment, and induction of hospitalization in primary health centers discovered during the supervision process, the county health and health commission is required to take the responsibility of the main body of supervision and improve relevant systems and mechanisms to prevent such problems.

“We seized the opportunity of the pilot innovation of the supervision method of the national medical insurance fund, and promoted the joint supervision of departments, the third-party joint inspection supervision and supervision, and the supervision of the Commission for Discipline Inspection and Supervision, forming a medical insurance fund supervision’co-management joint’ model.” The relevant person in charge of the Huai’an Discipline Inspection Commission introduced that the city regularly convenes joint medical insurance work conferences attended by discipline inspection and supervision, medical insurance, health, public security, market supervision and other departments, and established important information notification, joint inspection, clue transfer, and joint punishment The four working mechanisms are used to form a fist, forming a governance force.

At the same time, the Huai’an Municipal Commission for Discipline Inspection pays attention to solving “big problems” through “small cuts”, focusing on the frequent occurrence of fraudulent insurance in primary hospitals discovered during the supervision process, and the Municipal Health Commission The Municipal Medical Insurance Bureau conducted in-depth investigations, visited 14 primary health centers, interviewed 63 people, and unearthed deep-seated reasons such as inadequate fund payment, imperfect feedback and appeal mechanism, obvious priority to punishment, and serious loss of backbone talents. The special investigation report is submitted to the main leaders of the municipal party committee to promote the transformation of tangible supervision to effective supervision. At the same time, dig deep into the root cause of the problem, find out the difficult points, study and formulate the “Implementation Plan on Supervision and Promotion of the City’s Medical Insurance Fund Supervision Work”, and clearly focus on the four key points of medical insurance system reform, industry style construction, key work promotion, and typical problems The content is subject to normal supervision to promote the formation of a long-term supervision mechanism.

“While the people who violate discipline and law are held accountable, the root cause of the problem should be investigated in depth, and relevant units should be promoted to fill in the shortcomings of the system and plug the loopholes in supervision. Only by continuously consolidating the results of special supervision in the field of people’s livelihood and medical care Ye Bei, deputy secretary of the Huai’an Municipal Commission for Discipline Inspection and deputy director of the Municipal Supervision Commission, said that the next step will be to formulate and issue recommendations for units and regions with high incidence of problems, and earnestly give full play to the functions of disciplinary inspection and supervision recommendations for error correction, disposal, and root cause, with special supervision. “Small cuts” promote the implementation of long-term mechanism “big articles”. (Li Ying Zhang Jin)