A few days ago, a patient reported that the Second People’s Hospital of Wuhu City, Anhui Province (hereinafter referred to as "Wuhu Second Hospital") overcharged medical expenses, which aroused strong concern in the industry about "excessive diagnosis and treatment".

On December 2nd, Anhui Medical Insurance Bureau informed the Second Hospital of Wuhu about the illegal use of medical insurance funds, and on the 4th, official website of Hunan Medical Insurance Bureau issued the "Administrative Punishment of Xiangya Hospital of Central South University", which fined the hospital about 980,000 yuan for illegal use of medical insurance funds.

CBN found that in recent years, the Regulations on the Supervision and Administration of the Use of Medical Insurance Funds (hereinafter referred to as the Administrative Regulations) and the Interim Measures for the Supervision and Administration of the Use of Medical Insurance Funds (hereinafter referred to as the Interim Measures) and other laws and regulations have been promulgated one after another, providing policy and legal basis for the supervision of medical insurance funds; As a complement to the Interim Measures, the Measures for Reporting Incentives for Illegal Use of Medical Insurance Funds (hereinafter referred to as the "Incentive Measures") was also released in November 2022. This document is to mobilize social forces to participate in fund supervision and safeguard the safety of medical insurance funds.

The National Medical Insurance Bureau has repeatedly stressed that the medical insurance fund will never become "Tang monk meat". According to official data, since 2019, the National Medical Insurance Bureau has sent a total of 184 flight inspection teams to inspect 384 designated medical institutions, and found that 4.35 billion yuan of related funds were used illegally. Since the implementation of the "Incentive Measures" in January this year, medical insurance departments at all levels across the country have verified and recovered the amount of medical insurance violations of 158 million yuan according to the clues reported by the masses.

An expert on medical insurance policy told CBN that with the increasing efforts to crack down on fraudulent medical insurance in China, blatant fraudulent medical insurance behaviors such as "fake patients", "fake services", "fake medical products" and "fake medical insurance expenses" have been effectively curbed, but some fraudulent medical insurance behaviors have also shifted from the front to the back, and gradually changed to behaviors such as excessive medical treatment and excessive fees. How to determine the boundary of excessive medical treatment and how to adopt scientific and accurate comprehensive management methods are the key points in the next stage.

The boundary of "excessive diagnosis and treatment"

According to the notification of Anhui Medical Insurance Bureau, Wuhu Medical Insurance Bureau has fully recovered the medical insurance fund illegally used by Wuhu Second Hospital according to the medical insurance service agreement signed by the hospital, and deducted the liquidated damages at 30%, interviewed the relevant person in charge of the hospital, and handed it over to the public security and health care departments for further verification. At the same time, the bureau has started the administrative punishment procedure in accordance with the Management Regulations.

"Medical insurance service agreements are handled in different ways, but most medical institutions deduct liquidated damages at a rate of 30%." A person in charge of the medical reform department of a health and wellness commission in the southern region told the reporter that in addition to the treatment method according to the medical insurance service agreement, in the administrative punishment procedure, the above-mentioned "Management Regulations" stipulates that illegal acts that cause losses to the medical insurance fund shall be ordered to return, and a fine of more than 1 time and less than 2 times shall be imposed.

Zhao Dahai, a professor at the School of International and Public Affairs of Shanghai Jiaotong University, told the First Financial Reporter that whether it is for medical institutions or medical staff, the end of over-diagnosis and treatment must bring economic returns to themselves and institutions (institutions also involve scale expansion), but in the final analysis, the supervision of medical insurance funds needs a set of strict, scientific and legally effective standards to judge and identify.

"For public hospitals, we can constantly correct their use of medical insurance funds by strengthening supervision, but private hospitals and pharmacies have certain commercial attributes, so we still need to rely on effective supervision methods when avoiding the risk of fraudulent insurance." Zhao Dahai said that in the next stage, health care and medical insurance departments can jointly promote the standardization and implementation of clinical diagnosis and treatment paths.

To this end, the person in charge of the medical insurance service department of a top-three hospital in Beijing said that at any time, medical institutions should never make profits by prescribing drugs and consumables without collecting the information of the insured. This is malicious fraud and insurance fraud, and it is also the bottom line problem. However, at this stage, it is not uncommon for medical institutions to occupy too much medical insurance funds by improving the accessibility of drugs and consumables.

"But whether this belongs to’ excessive diagnosis and treatment’ needs to be viewed objectively." The person in charge said that on the one hand, some innovative drugs are expensive but have great benefits to diseases, and doctors prescribe them for patients out of kindness. However, due to the annual update of the medical insurance catalogue, whether the innovative drugs are still within the scope of the medical insurance catalogue, whether the medical insurance limited payment ratio has been adjusted, and whether the patient’s area is applicable need further careful confirmation. On the other hand, the scope of medical insurance fund’s limited payment needs to refer to a number of matters, including the indications in the drug instructions and the reimbursement ratio of the insured’s location. "It is almost impossible for doctors to record all the contents and ensure that there are no mistakes. Therefore, it is imperative to introduce an information-assisted platform and do a good job in training."

Is there a solution to the problem that medical institutions illegally use medical insurance funds caused by "excessive diagnosis and treatment"?

Cai Haiqing, former director of the Treatment Protection Department of Jiangxi Provincial Medical Insurance Bureau, said that, first of all, it is necessary to solve the problem of how to identify "excessive diagnosis and treatment"; Secondly, with the comprehensive implementation of the reform of DRGs (Payment by Disease Diagnosis Group) and DIG (Payment by Disease Score), the problem of medical insurance payment currently facing the clinic is to solve the problem of "over-diagnosis and treatment" and to prevent possible insufficient diagnosis and treatment. "Insufficient diagnosis and treatment includes low-standard discharge, reducing necessary medical services and inspection items, and reducing the use of drugs and consumables. This situation is to reduce the cost of medical services and improve the yield."

As a matter of fact, the First Financial Reporter learned in the industry that it is difficult to identify, identify and dispose of over-medical treatment. In June this year, "Research on the Identification of Over-medical Treatment Behavior and the Regulation Rules of Medical Insurance" released the first "over-medical treatment index system". The theoretical basis of this system includes sampling data, written materials and written materials of fund supervision discussions of 121 designated medical insurance institutions in Shanghai. It involves 5 first-level indicators, 30 second-level indicators and 67 third-level indicators.

"Although the system is developed in the form of research, it is still some time before it is fully implemented, but at least it has broken the definition of the boundary of overtreatment." Cai Haiqing said.

Regulatory challenges

Since the beginning of this year, official website, the National Medical Insurance Bureau, has published 40 typical cases of fraudulent insurance in four phases. The illegal use of medical insurance funds includes: changing medical treatment items, falsely recording infusion drugs, treatment and inspection fees, forging materials, uploading false medication data, etc. Most of these cases were discovered by local medical insurance departments through active forms such as medical data verification in different places, big data screening and analysis, and on-site supervision and inspection.

On the basis of the previous vigorous rectification work, what are the challenges in the supervision of medical insurance funds and how to establish a long-term supervision mechanism?

To this end, Yu Changyong, an associate professor at the School of Public Administration of Zhongnan University of Economics and Law, told reporters that under the new situation, the new challenges of China’s medical insurance fund supervision can be interpreted from four aspects. First of all, after years of flight inspection and special work to combat fraud and insurance fraud, some "blatant" fraud and insurance fraud in the past have been effectively curbed, and the means of fraud and insurance fraud will be more subtle and the way of fraud will be more complicated.

Secondly, the overall level of medical insurance in various regions has been gradually improved, and the area where patients seek medical treatment has become larger, which will also significantly expand the scope of supervision of medical insurance funds and increase the difficulty of supervision. Thirdly, the reform of outpatient co-ordination makes the medical insurance department not only supervise the hospitalization behavior, but also supervise the outpatient behavior and the drug purchase behavior of pharmacies, and the objects and contents of supervision will show explosive growth.

In addition, the state attaches great importance to the development of Chinese medicine, and Chinese medicine services will be further included in the scope of medical insurance fund payment. However, Chinese medicine services are often treated by people and diseases, and its legal compliance or more difficult to judge, making it more difficult to supervise medical insurance funds.

To this end, Yu Changyong suggested that for some hidden and complicated illegal use of medical insurance funds, the medical insurance administrative department needs to be accurate and qualitative, and administer according to law; On the other hand, it is necessary to increase administrative punishment and even criminal punishment. In addition, it is necessary to strengthen the construction of intelligent monitoring and big data screening mechanisms, and establish a credit supervision system as soon as possible.

For the establishment of a long-term mechanism, a medical insurance fund supervisor said that in fact, in the past, the punishment for illegal use of medical insurance funds was mostly in medical institutions, and the punishment for individuals was not enough; At the same time, due to the low cost of violating laws and regulations, in most cases, it is ultimately handled in accordance with the medical insurance service agreement, and administrative punishment, transfer to justice or discipline inspection are rare.

"On the one hand, it is recommended that the medical insurance department unify the standards for law enforcement and incorporate illegal acts of medical institutions into credit management; On the other hand, medical institutions should establish the accountability system, reward and punishment system for the main leaders of the party and government and department heads, and improve the business training in the field of medical insurance payment. In addition, it is necessary to improve the comprehensive supervision mechanism that pays equal attention to incentives and constraints. Medical institutions that self-examine and self-correct and voluntarily return funds can reduce or not be punished. However, for those medical institutions and individuals who repeatedly check recidivism and do not change, they must be dealt with severely. " The source said.

At 8 pm on June 15th, 2023, the world cup champion Argentina men’s soccer team will come to Beijing Workers Stadium to play an international match with the Australian men’s soccer team.

Messi, the king of football, really came to Gundy! Never mind the ticket price, the new workers are going to blow up!

It is a satisfaction for fans to see the skills of the world cup champion with their own eyes. Disappointingly, the China Football Association also announced that the China men’s soccer team will participate in the Dalian International Football Invitational Tournament, while the national team’s opponents will be Myanmar and Palestine.

Messi is very depressed. I went to the national team with the most fans in the world, but they didn’t play football with me.

Why doesn’t the national football team play against Argentina? When the media organizer asked the Football Association, Du Zhaocai said, "There is no need for the national football team to compete with the Argentine national team. This is the confidence of the Football Association." National football team. "This may be to prevent being hit," he said.

On the day of the international football match in June, the second round of the Super League will be cancelled, and Beijing Guoan players will be able to watch Messi in the courtyard.

To put it bluntly, the football match between the national football team and the Argentine national team was disdained by the fans because of the low level of football in China. Or improve your league.

In this week’s Super League, there was a match between Beijing and Shanghai, and Beijing Guoan challenged Shanghai Shenhua away. Ma Ning served as the referee, and football coach jankovic inspected the players on the spot.

Live broadcast November 30th. According to Beiqing report, Li Tie himself recently found Chen Yiyuan, chairman of the Chinese Football Association, profoundly self -review and sincere apology.mean.

For Li Tie’s future, the Chinese Football Association will submit a report to the superior management department. After approval, it will announce the final result through official channels in December.

Li Tie brought the country’s feet this afternoon to the last outdoor training of this closed training at the Taihu Taihu Football Base in Suzhou.Subsequently, the team will take one day on December 1 and be collectively transferred to Shanghai on December 2 to receive "independent observation".Because some Chinese Super League teams have recently come to Shanghai to prepare for the Chinese Super League, some of the national football will directly meet with the club troops, and the national football coaching team will not arrange any collective training in Shanghai.

On April 19, a courier rider was delivered to Jiujiang Road, Bund Street. Two buss had just pulled away a close contact with a group of new crown pneumonians from here and sent them to Hangzhou, Zhejiang. China Youth Daily · Zhongqing.com reporter Li Qiang/Photo

On April 14, a "head" of the community group purchase of community group purchases was inspecting the group purchase list, which was in front of her soybean products. China Youth Daily · Zhongqing.com reporter Li Qiang/Photo

Photography report | | Li Qiang

This spring, because of the new crown pneumonia, "Magic Capital" Shanghai encountered some problems. For a modern metropolis, in the face of stores and pharmacies, it is difficult to solve the problem of 25 million people to eat and see a doctor in the face of the closing of stores and pharmacies. Conservation has become a big thing.

A citizen living in Yangpu District, Shanghai said that she set up three different platforms to grab the food alarm clock every day: at 12 o’clock in the night, grabbing Sam or US cuisine, at 6 am, and 8 o’clock in the Hema. Nevertheless, she was always "not snatched." The daily greetings of people’s daily greetings are, "Today, have you grabbed the dishes?" The young people who were accustomed to shopping online were tossed online and tossed, and those who had not learned to use smartphones could only be Waiting for assistance.

At the press conference on April 16, Liu Min, deputy director of the Shanghai Municipal Commercial Committee, said that for some time, the problem of difficulty in shopping on online shopping in Shanghai was mainly because many takeaway riders were sealed in the community. Temporarily closed due to the requirements of epidemic prevention, which allows e -commerce to protect the supply ability. In addition, due to the upgrading of the epidemic situation in some places, the land transportation and logistics in some areas are not good, and some living and production materials are blocked on the road, which also affects Shanghai’s confession.

In order to send materials to the people, a company guaranteed enterprises to transfer 160 experienced and professional employees to support warehouse operations from Wuhan, Guangzhou, Shenzhen, Beijing, Kunming and other places. In this warehouse for enterprises, the reporter saw a truck sending vegetables. The packant was packed into a box after disinfection of vegetables and transferred to the delivery staff. There are many people who have been temporarily changed to join the delivery team. Some of them were online car drivers, some were driving a photography studio, and some people just came to Shanghai from Inner Mongolia to find a job, but happened to encounter the epidemic.

The rider who was trapped in the community also came out to solve the problem of "last mile". Although they were informed that they could not go back after being out of the community, they still chose to go to the streets to deliver life and medical supplies for citizens. The rider who could not solve the problem of accommodation had to sleep on the street at night. Now on the empty streets of Shanghai, they are the busiest people. They buy fruits, vegetables, meat, and medicines, take pets for pets, and then distribute them in time. On the street electric vehicles, various living materials bags are often hung.

On the evening of April 9th, there were many riders who were waiting to buy goods in Huangpu District, Huangpu District, Shanghai. When a citizen passed by, he looked down curiously. China Youth Daily · Zhongqing.com reporter Li Qiang/Photo

On the evening of April 9, a fruit shop opened the door for a half -door business. Many riders were waiting to pick up the order to buy fruit, drinks, and eggs for customers. China Youth Daily · Zhongqing.com reporter Li Qiang/Photo

On April 12, two takeaway riders were resting on the street. They came from Baotou (left) in Inner Mongolia (left) and Kashgar (right) in Xinjiang. In the early days of the epidemic, they were sealed at home. On April 7, they went out of the rented community to deliver takeaway to deliver life and medical supplies for citizens. Since the community no longer allows to enter, they have to temporarily live on the street. China Youth Daily · Zhongqing.com reporter Li Qiang/Photo

On April 19, a rider walked out of the street’s residence. After going out, because the community was not allowed to enter again, many riders who had nowhere to stay had to choose to temporarily live on the street. The rider used a cloth to separate a piece of space in front of a snack bar. China Youth Daily · Zhongqing.com reporter Li Qiang/Photo

On April 12, Huangpu District, Shanghai, was divided into Yuyuan Street, which was divided into a preventive area. A business shop counter was filled with medicine waiting for delivery. China Youth Daily · Zhongqing.com reporter Li Qiang/Photo

On April 12, Huangpu District, Shanghai, was divided into Yuyuan Street, which was divided into a preventive area. China Youth Daily · Zhongqing.com reporter Li Qiang/Photo

On April 14th, in front of Huangpu District, Shanghai, a rider received a pet medication for customers on behalf of the customer. China Youth Daily · Zhongqing.com reporter Li Qiang/Photo

On April 11, a large number of orders waiting for delivery were placed in Songjiang District, Shanghai, Shanghai, Songjiang District, Shanghai. The staff told reporters that after returning to business, the online orders quickly "exploded". Due to limited manpower, each time they dared to turn on the system for a few seconds. China Youth Daily · Zhongqing.com reporter Li Qiang/Photo

On April 17, in Qingpu District, Shanghai, a courier company’s warehouse was full of epidemic prevention supplies that were about to be sent to various communities in Shanghai. This is a group of enterprises donated 10 million yuan of epidemic prevention materials. It will be sent to nearly 200 residential (village) committees and 200,000 families in Shanghai. China Youth Daily · Zhongqing.com reporter Li Qiang/Photo

On April 10, Pudong New District, Shanghai, a warehouse in Shanghai’s supply enterprise was stored in government group purchases, and was ready to send it. The guarantee enterprises have dispatched 160 experienced logistics professional employees to support Shanghai from Wuhan, Guangzhou, Shenzhen, Beijing, Chengdu, Kunming and other places to support Shanghai, so that the warehouse matching system can continue to operate. China Youth Daily · Zhongqing.com reporter Li Qiang/Photo

On April 10th, a truck was provided in the warehouse of the enterprise in Pudong New District, Shanghai, and a truck was sent to vegetables, including radishes and cabbage. When unloading, each bag of vegetables need to be disinfected. China Youth Daily · Zhongqing.com reporter Li Qiang/Photo

On April 10, in the Pudong New District of Shanghai, a provider was inside the enterprise warehouse, and a distributor dragged the packed living materials outside the door to prepare to load the car. China Youth Daily · Zhongqing.com reporter Li Qiang/Photo

On April 10, the Pudong New District of Shanghai, a certain guarantee in the enterprise warehouse, the delivery staff were resting. Many of these distributors are temporarily changed. They originally came from all walks of life. Some people were previously online car drivers. Some people drove a photography studio. Some people just came to Shanghai from Inner Mongolia to find a job. China Youth Daily · Zhongqing.com reporter Li Qiang/Photo

On April 19, a rider was driving near the street near the Bund. Not far away is the Oriental Pearl TV Tower, which has been suspended.

On April 19, a rider in Huangpu District, Shanghai was driving on the South Suzhou Road. The Daba chrysanthemum beside the Suzhou River was flourishing, but there were few pedestrians on the road. Occasionally someone walked the dogs, and some people who couldn’t get out of the door leaned against the window. China Youth Daily · Zhongqing.com reporter Li Qiang/Photo

Residents are actively helping themselves in places where the outside world guarantees cannot be reached.

Community group purchases have become an important way for self -rescue of civilians. In many communities in Shanghai, "egg group", "vegetable group", "fruit group" and "milk group" appeared. In a hotel in Minhang District, Chinese and foreign lives are "head" to help everyone buy different materials. The "head of the group" sought their own supply channels and delivery riders. When people grabbing food on the Internet failed, they could always try to get the goods.

In the mutual aid group of Caojiaxiang District, Putuo District, the "Easy Protective" that disappeared from modern daily life became a normal state. Someone took out coffee and wine and replaced vegetables and eggs. In the corridor of the community, people can often see the goods packed with various bags in front of a house. After a hungry resident for many days in the group for help, other residents and volunteers of Lou Dong sent food spontaneously.

At night, some small shops on the street will quietly open the rolling door. The citizens nearby take the time to do nucleic acid testing and go to the temporary grocery store to supplement their living materials. After the riders learned that there was a good news of a fruit shop, they rushed to the shop waiting for the list to buy fruit for customers. Other shops choose to close the door. After the citizen is paid online and down, the rider will be available to the store to pick up the goods.

Some people even start buying vegetables seeds online, planting vegetables on the balcony, or digging wild vegetables on the community. An Anhui person who is a driver in Shanghai all year round becomes a community volunteer. Every day, in addition to the medical staff who sent the medical staff of the Anhui medical team to and from the nuclear acid sampling point, he will also give the extra box lunch to the rental house, and then Fellows who can’t buy life materials. Wanderers on the street can occasionally eat their extra box lunch.

On the evening of April 9th, a grocery store opened the store to provide living materials to guarantee living materials for nearby citizens. A citizen was buying drinks and wine in the store. China Youth Daily · Zhongqing.com reporter Li Qiang/Photo

On April 12, in Xuhui District, Shanghai, in a community belonging to the seal -and -control area, residents took the car to the living materials storage point to pick up materials. China Youth Daily · Zhongqing.com reporter Li Qiang/Photo

On April 12, a elderly person went to Yifeng Da Pharmacy in Yuyuan Street to buy medicines. China Youth Daily · Zhongqing.com reporter Li Qiang/Photo

On April 12, a citizen in Huangpu District, Shanghai, walked out of the house to buy fruits. China Youth Daily · Zhongqing.com reporter Li Qiang/Photo

On April 11, the takeaway transfer point in front of a supermarket door in Songjiang District, Shanghai. China Youth Daily · Zhongqing.com reporter Li Qiang/Photo

On April 14, a community volunteer in the fourth grade of elementary school in Shanghai was instructed by an unmanned delivery vehicle to park medicine. In this community, 4 unmanned delivery vehicles solve the problem of the last 100 meters of residents’ living materials. China Youth Daily · Zhongqing.com reporter Li Qiang/Photo

On April 14th, a bicycle in Shanghai Pudong New Area, a bicycle was carrying the purchased hoe and other living materials in a closed management community. China Youth Daily · Zhongqing.com reporter Li Qiang/Photo

At the same time, Shanghai is also trying to restore capacity to promote commercial node outlets such as Datang and front warehouses in e -commerce platforms. On April 16, the press conference of the Shanghai New Crown Pneumonia’s Epidemium Prevention and Control revealed that the Shanghai e -commerce platform has been restored to 42 business. 779 are restored before the immune -related warehouse, and the number of takeaway rides is more than 18,000. The daily delivery single volume is about 1.8 million orders.

On April 20, some media learned from the Shanghai Municipal Commercial Commission that "Shanghai Vegetable Insurance Supply of the Wholesale Business Transfer Station" was established in the Jiangqiao wholesale market, encouraging and supporting vegetable wholesale operation enterprises and operating households across the country to actively organize the supply of supply, through Jiangqiao The transit station is transferred to the Jiangqiao wholesale market transaction and continues to supply the Shanghai market. The long -lasting war of this confession is gradually getting out of the predicament under the investment of officials and folk forces.