Illegal use of medical insurance funds

1. Forge false medical service bills to defraud the medical insurance fund.

Patients falsely issue invoices for medical treatment and drug purchase through acquaintances, and submit relevant bills to medical insurance agencies for manual sporadic reimbursement through forged medical records.

Two, lend my medical insurance identity certificate to others for medical treatment or hold another person's medical insurance identity certificate under the guise of medical treatment.

1. Due to medical insurance arrears, I need to see a doctor during the waiting period, and I used my relatives' social security cards to see a doctor and buy medicine.

2. During the period of serving the sentence, medical personnel released on parole use their relatives' social security cards for hospitalization reimbursement.

Three, illegal use of medical insurance identity documents, taking medicine consumables.

Patients take advantage of the high reimbursement rate of uremic dialysis patients and prescribe drugs for hypertension and diabetes to other chronic diseases such as hypertension and diabetes for a long time.

4. Other fraudulent insurance behaviors involving the insured.

1. The patient has medical insurance benefits for employees from other provinces and has participated in medical insurance for urban and rural residents in Xuzhou for many times. After being hospitalized in other places, he will take relevant bills to Xuzhou medical insurance agency to apply for manual sporadic reimbursement.

2. After the traffic accident, the traffic police determined that the perpetrator was fully responsible, and the perpetrator and the injured party negotiated privately to give certain economic compensation, and asked the injured party to use medical insurance for hospitalization reimbursement. The injured party deliberately concealed the injury process during the trauma investigation and used medical insurance for reimbursement.

medical institution

First, over-diagnosis and over-examination in violation of the norms of diagnosis and treatment.

1. Single hospitalization, no need to repeat blood type, blood lipid and tumor markers.

2. At the same time, the same part is charged for fumigation and washing treatment, steam bath treatment and fumigation treatment.

3. Non-rehabilitation inpatients are charged with rehabilitation assessment fees, such as "assessment of daily living ability".

4. Other excessive medical behaviors identified by the health department.

Two, in violation of the provisions of the price of repeated charges, excessive charges, decomposition of project charges.

1. Nursing fees and bed fees are calculated according to the method of counting and excluding, and bed fees and nursing fees are charged for those who exceed the hospitalization days.

2. Charge the "oxygen inhalation" fee for more than the hospitalization time, and charge the "oxygen inhalation" fee every day, which exceeds the 65 yuan capping line.

3. For intensive care or special care, special care fee will be charged separately.

4. For intravenous infusion, materials including disposable infusion set and disposable dispensing syringe are charged.

5. When the indwelling needle is used for intravenous infusion, the fees of "venipuncture catheterization" and "arteriovenous catheterization nursing" will be charged respectively.

6. When using single infusion such as compound amino acids and fat-soluble vitamins, the fee of "intravenous hypernutrition therapy" will be charged.

7. When collecting the nursing fee for sputum suction, the fee of "mechanically assisted sputum discharge" will be charged repeatedly.

8. The nursing fee includes the monitoring of vital signs such as measuring the patient's temperature, pulse, blood pressure and respiration, and the measurement fee of temperature, pulse, blood pressure and respiration is charged repeatedly.

9. When "color Doppler echocardiography" is performed, the fees for "ordinary M-mode echocardiography" and "ordinary two-dimensional echocardiography" will be charged respectively.

10. When "bedside B-ultrasound examination" is performed, the fee for "routine B-ultrasound examination" is charged repeatedly.

1 1. When carrying out the same ultrasonic examination project, the fees of "color film report" and "computer graphic report" will be charged at the same time.

12. When carrying out the same ultrasonic examination project, the fees of "computer graphic report" and "color printing photos" will be charged at the same time.

13. Ordinary color ultrasound examination should be charged according to "location", not according to the number of organs and each blood vessel; To carry out color Doppler ultrasound examination of blood vessels in limbs, fees should be charged according to "each limb", and fees should not be charged according to the decomposition of each blood vessel.

14. Except for color Doppler ultrasound examination of cervical vessels (including carotid artery, jugular vein, vertebral artery and subclavian artery), special color Doppler ultrasound examination is charged for each vessel.

15. When "ABO blood group identification (card method)" is carried out, the fee for "RHD blood group identification" will also be charged.

16. Perform "general anesthesia" and repeatedly charge the fees for "tracheal intubation" and "special method tracheal intubation".

17. "ECG monitoring" was carried out, and "ambulatory blood pressure monitoring" was charged at the same time.

18. Transvascular interventional therapy was performed, and local infiltration anesthesia, puncture, injection and urethral catheterization were charged repeatedly.

19. Carry out endoscopic treatment, and charge the endoscopic examination fee repeatedly.

20. Conduct a digestive endoscopy through the oral cavity or nasal cavity, and conduct inspection according to nasal endoscope, laryngoscope and bronchoscope.

2 1. If the name of the surgical treatment project is "XX surgery through XX mirror", the "extra charge for minimally invasive surgery" and various endoscopic fees will be charged repeatedly.

22 to carry out all kinds of exploration, only applicable to the original operation interrupted by unclear preoperative diagnosis or incomplete operation, and shall not be charged at the same time with other surgical projects.

23. To carry out low-frequency and intermediate-frequency pulse electrotherapy and targeted drug penetration therapy in traditional Chinese medicine, fees should be charged according to "each part", and repeated fees should be calculated according to the number of electrode pieces.

24. Divide a barotherapy process of the same limb into multiple parts for charging.

25. Routine instruments and low-value medical consumables included in the connotation of surgical projects are charged repeatedly (such as disposable sterile towels, syringes, washing saline, common sutures, dressings, etc.). ).

26. "Monitoring during anesthesia" includes end-expiratory carbon dioxide measurement, and the cost of "carbon dioxide response curve" is charged repeatedly.

27 other illegal charges identified by the competent price department.

Three. Exchanging medicines, medical consumables, diagnosis and treatment items and service facilities.

1. When carrying out pathological examination and diagnosis of ordinary large specimens, the fee is changed to "pathological examination and diagnosis of large slices of whole organs".

2. When drug gene testing is carried out, the fees are changed to pathological examination items such as "protein blot hybridization technology" and "in situ hybridization technology".

3. Carry out the pain nursing evaluation, and exchange the fees according to the "comprehensive pain evaluation".

4 to carry out health education and publicity, according to the "guided education and training" charges.

5 can not be charged for the exchange of goods, according to the "special materials" charges. (such as: disposable laminar flow cover, disposable delivery bag, disposable dressing bag, nursing bag, magnetic tape printed wristband, preparation bag, specimen bag, medical sterile protective cover, nursing pad, quicklime, disposable sterile gloves, microscope cover, decompression patch, gynecological material fee, surgical irrigator, disposable orthopedic surgical bag, disposable surgical bag, disposable nail box, etc.). ).

6 nasal feeding, drug injection, the charge is changed to "enteral nutrition therapy".

7. When carrying out wet chemical tests such as serum albumin determination, glucose determination, potassium determination and sodium determination. It is charged by dry chemical method.

8. Carry out "visible light therapy" such as red light irradiation and blue light irradiation, and charge for "laser therapy".

9. The postoperative "analgesic device" (Class C) is charged by "automatic drug injection pump" (Class B).

Four, do not belong to the medical insurance fund payment scope of medical expenses into the medical insurance fund settlement.

1. Payment limit for drugs other than medical insurance

(1) Thymoprofloxacin for injection and botulinum toxin A for injection are limited to work-related injuries, and the part of medical insurance that exceeds the payment is reimbursed by the medical insurance fund.

(2) Ceftimidine for injection is limited to patients with clear evidence of drug sensitivity test or severe infection, and the medical insurance fund will reimburse the part beyond the medical insurance payment.

(3) Rabeprazole sodium for injection is limited to patients with disease diagnosis, fasting or dysphagia indicated in the instructions, and the medical insurance fund is used for reimbursement.

(4) Patients with megaloblastic anemia due to vitamin B 12 deficiency who cannot use oral mecobalamin due to fasting or dysphagia shall be reimbursed by the medical insurance fund.

2. Out-of-range charges for diagnosis and treatment projects

(1) Patients with non-communicable diseases are charged a "disposable tourniquet" fee.

(2) Children's intravenous infusion refers to preschool children (under 6 years old), and children over 6 years old are charged according to this item.

(3) no gas gangrene, tetanus, AIDS and other special infectious diseases, charge "special disease health care fee".

Five, induce and assist others to impersonate or buy medicines for medical treatment, provide false proof materials, and fabricate medical services.

1. Doctors write adult prescriptions and use adult medical insurance cards to treat children and buy medicines, even though they know that the patients actually treated are children.

2. During the damage of the wax therapy machine, the hospital still fabricated medical services for "wax therapy" and charged patients.

3.CT examination does not carry out three-dimensional imaging of blood vessels, gallbladder, CTVE, heart, brain and bone, but charges for "CT imaging".

Designated drugstore

One is to steal medical insurance identity documents, collect cash for the insured or buy non-medical items such as nutrition and health products, cosmetics and daily necessities.

1. The staff of the pharmacy saw that the balance of the insured's medical insurance card was very large, and even swiped two fees without the insured's knowledge, only billing the insured, which made the insured mistakenly think that only one fee was swiped.

2. The pharmacy staff will empty the personal account of the insured person's medical insurance card and divide it into cash in proportion with the insured person.

3. Pharmacy staff will use personal accounts to settle items that should be sold in cash, such as health brand name, makeup brand name, masks and iodophors.

Two, for the insured to adjust drugs, consumables, articles and other fraudulent medical insurance fund expenditure.

1. In order to facilitate the insured to accumulate enough threshold fees and fill up the overall fund, the pharmacy staff changed the B drugs actually purchased by patients to Class A drugs for filling up.

2. Patients purchase equipment consumables such as sphygmomanometer and thermometer, and the staff will pay by credit card according to generally reimbursable drugs.

Three, to provide credit card settlement services for non designated medical institutions.

1. The pharmaceutical chain company, knowing that the newly opened pharmacy has not handled the designated medical insurance, sells the medicine first, and then takes the insured's medical insurance card to the designated chain pharmacy for credit card settlement.

2. While knowing that the newly-opened pharmacy has not handled the designated medical insurance, privately pull the credit card limit of the designated pharmacy for credit card settlement.

4. False invoices provide false invoices for the insured and the insured.

At the end of the year, there is a second reimbursement policy within the insured unit. In order to cooperate with the insured to enjoy the corresponding treatment, medical institutions swipe their cards or empty them in advance without actual medical services, and provide invoices for drug purchase.

Five, other violations of designated retail pharmacies and their staff.

1. The identity information of the cardholder was not checked before the credit card was sold, resulting in the lost medical insurance card of the insured being used by others under an assumed name.

2. Chinese herbal medicines with the same origin of medicine and food, such as pepper, star anise, black sesame, jujube, etc., will not be paid when they are used alone, and the prescriptions composed of all these pieces will not be paid. Designated retail pharmacies and their staff violate the restrictive requirements and let the insured pay by credit card.