Chongqing Fuling District Human Resources and Social Security Bureau Document

Fu Ren She Fa [2112] No.74

Chongqing Fuling District Human Resources and Social Security Bureau

Notice on medical insurance violations in Pok Oi Hospital

Designated medical institutions and retail pharmacies:

At the beginning of May, 2112, people visited and reported that Pok Oi Hospital was in the service behavior of inpatient treatment. After investigation and verification, the hospital mainly has inflated the number of drugs and overcharged the inspection items, and the internal management is chaotic, which leads to the untrue contents of the inpatient medical records and the inconsistency between the medical insurance reimbursement records filled in and the reimbursement information in the medical insurance network. It has seriously violated the relevant provisions of the Interim Measures for the Supervision and Administration of Medical Insurance Services in Chongqing (No.23 [2112] of Yu Ren She Fa) and the Interim Measures for the Administration of Medical Insurance Designated Medical Institutions in Fuling District of Chongqing (No.42 [2111] of Fu Fu Fu Fa).

The illegal behavior of Pok Oi Hospital has caused extremely negative influence in the whole region, and also exposed the weak links and problems existing in the daily management of the hospital. In order to draw a profound lesson from this incident, this Council decided to impose administrative and economic penalties on Pok Oi Hospital, give it to informed criticism within the scope of "two institutions" in the whole region, and order it to make rectification within a time limit, so as to urge it to change its service attitude and improve its service quality.

I hope that all designated medical institutions and retail pharmacies in the whole region will take a warning, draw inferences from others, further strengthen internal daily management, strengthen medical insurance policy learning, be familiar with medical insurance management processes, and firmly establish a sense of responsibility and service. It is necessary to strengthen communication with patients and their families, attach great importance to and promptly investigate and deal with patients' demands, prevent similar situations from happening again, strive to achieve the goal of zero complaints in medical insurance management, effectively provide high-quality medical insurance services for patients, and promote the healthy and orderly development of medical insurance in our region. All units are requested to carry out a self-inspection activity for the problems exposed by Pok Oi Hospital, and form a written report before July 31, and then send it to this bureau, and send a copy to the district medical insurance center.

this is for your information.

Attachment: Notice of Chongqing Fuling District Human Resources and Social Security Bureau on Handling Medical Insurance Violations in Pok Oi Hospital

July 18th, 2112

Attachment:

Notice on Handling Medical Insurance Violations in Pok Oi Hospital

Chongqing Fuling District Human Resources and Social Security Bureau

(July 18th, 2112)

Pok Oi Hospital: < p According to the Interim Measures for the Supervision and Administration of Medical Insurance Services in Chongqing (No.23 [2112] of Yu Ren She Fa) and the Interim Measures for the Administration of Designated Medical Institutions of Medical Insurance in Fuling District of Chongqing (No.42 [2111] of Fu Fu Fu Fa), we hereby notify you of the decision on the handling of violations in your hospital as follows:

1. The facts of violations

(1) False. First, patient Chen Mou was admitted to the hospital on April 26th, 2112, and discharged from the hospital on the morning of May 5th. On the day of discharge, your hospital overcharged the patient for three days' treatment of drugs and treatment expenses. Second, patient Wenmou was admitted to the hospital on May 1 and discharged from the hospital on May 5. During the hospitalization, the dosage of Shuxuetong injection, cefoperazone sulbactam sodium, batroxobin and other drugs was the same as that of other patients, but the charged dosage in the patient's charge list was more than that of other patients.

(2) inflated inspection items and charged more. First, at the beginning of Chen Mou's admission, you charged for monitoring for 21 hours a day, but after her condition improved, she charged for monitoring for 24 hours a day, which was untrue. Second, patient Wen did not do ambulatory blood pressure monitoring and ECG monitoring during his hospitalization, but your hospital charged the fees for ambulatory blood pressure monitoring and ECG monitoring for two days.

(3) internal management confusion. First, the contents of hospital medical records are untrue. Patient Wen's hospitalization medical record records that the admission time is May 5 and the discharge time is May 1, which is inconsistent; In the inpatient medical record of patient Yu, the temperature registration form records that he was discharged at 9:11 am on March 25th, but the course record shows that he was discharged at 9:11 am on March 26th. The discharge time in his nursing record was obviously changed from 25th to 26th, and the discharge time was inconsistent. Second, the medical insurance reimbursement record filled in by your hospital is inconsistent with the reimbursement information in the medical insurance network. The total medical expenses of patient Yu in the hospital are more than 2,111 yuan, and the total medical expenses are more than 711 yuan, but the reimbursement record registered on the medical insurance is 711 yuan, and the medical insurance reimbursement is 666.28 yuan; The medical insurance network shows that the total hospitalization expenses are 711 yuan, the medical insurance reimbursement is 479.12 yuan, and the individual bears 221.98 yuan. The reimbursement information of the three is inconsistent.

II. Handling Decision

According to the above facts, there are irregularities in the hospitalization services of Chen Mou, Wenmou and Yumou in your hospital. Among them, Chen Mou and Wenmou are involved in inflated drugs and overcharged and reimbursed for the number of inspection items, which are serious violations; Yu does not involve overcharge and reimbursement, but the medical insurance management is chaotic, which is a general violation of discipline. According to the relevant regulations of Yu Ren She Fa [2112] No.23 and Fu Fu Fa [2111] No.42, we decided to deal with your hospital as follows:

(1) admonishing conversation

The leaders in charge of this bureau and the relevant personnel of the medical insurance center * * * interviewed the main person in charge of your hospital, the dean in charge of business and the person in charge of the medical insurance office to inform them of the investigation results, conclusions and

(II) Economic penalty

1. Recover the funds of 9299.81 yuan (including: 6371.19 yuan for Chen Mou, 2449.69 yuan for Wenmou and 479.12 yuan for Yumou) that have been allocated to your hospital, and deduct them from other funds that should be allocated to your hospital.

2. Deduct the penalty of RMB 117451.31 from your hospital (in the hospitalization service of patients Chen Mou and Wenmou, if the circumstances are serious, it will be deducted according to the standard of 21% for each hospitalization reimbursement in your hospital in May 2112; In the hospitalization service of a patient, illegal reimbursement is a general violation of discipline, and the penalty is deducted according to the equal amount of reimbursement. Be sure to deposit it in the district medical insurance center within three working days.

3. Refund 841.59 yuan (including: 536.79 yuan in Chen Mou and 314.81 yuan in Wenmou) for the extra medical expenses incurred by the above patients due to inflated drug quantity in your hospital.

(3) The Bureau will conduct informed criticism on this illegal behavior of your hospital within the scope of "two institutions" in the whole region, and include it in the year-end service agreement evaluation.

(4) rectification within a time limit. First, order your hospital to strengthen the policy and business study of medical insurance management and handling personnel (this bureau can arrange comrades familiar with policies to preach in your hospital); Second, order your hospital to rectify within a time limit of 1 months from July 9, improve the medical insurance management system in the hospital, strengthen the medical insurance management and the responsibility of the handling personnel, establish the accountability system for violations, and improve the workflow, change the service attitude and improve the service quality. After the expiration of the rectification, your hospital will submit a written application for review. After the review, the bureau will organize relevant personnel to determine whether to continue the rectification and suspend the medical insurance network or cancel the medical insurance designated qualification, depending on their rectification attitude and the effect achieved.

this is for your information.

Keywords: Report on Handling Medical Insurance Violation

Office of Human Resources and Social Security Bureau of Fuling District, Chongqing Municipality printed

on July 8, 2112 (* * * printed in 6 copies.