Medical insurance funds are the “medical treatment funds” and “lifesaving funds” for the people, and no one is allowed to embezzle or misappropriate them. The “Implementation Opinions of the General Office of the State Council on Strengthening the Normalized Supervision of Medical Security Fund Utilization” emphasize strengthening the primary responsibility of designated medical and pharmaceutical institutions for self-management and require them to promptly conduct self-examination and self-correction. This year, the National Healthcare Security Administration (NHSA) summarized inspection results over the years to form a list of illegal and irregular issues for designated medical institutions, guiding them to actively conduct self-examination against the list and enhance the standardized level of medical insurance fund utilization through self-management. This is an important measure to guide designated medical institutions in fulfilling their primary responsibility for self-management, a significant embodiment of the concept of combining leniency and severity in the supervision of medical insurance funds, and an important way to empower designated medical institutions. During this year’s unannounced inspections, the NHSA found that some medical institutions perfunctorily dealt with self-examination and self-correction, did not actively conduct self-examination and rectification for issues listed, and severely failed to fulfill their primary responsibility for self-management. The following are some typical issues:
1. Inner Mongolia Autonomous Region People’s Hospital. Upon investigation, the hospital had 82 issues with an illegal and irregular amount of 34.667 million yuan, but the amount of medical insurance funds returned through self-examination and self-correction within the prescribed time was 0 (the hospital returned 32,300 yuan two weeks after the unannounced inspection ended), indicating a severe lack of self-examination and self-correction; Some of these issues had been previously pointed out in inspections, but the hospital did not completely rectify them, and they were still widespread during this inspection, showing repeated violations. Typical issues include:
– Overcharging. For example, “topical application therapy” should be charged based on “wound area,” with one charge per wound area, but the hospital charged based on the number of consumables used for the topical application. Similar issues existed in pathological diagnosis, bacterial culture, etc., involving costs of 4.239 million yuan.
– Overdiagnosis and overtreatment. For instance, “glycated hemoglobin” is clinically used as a monitoring indicator for diabetes. This indicator is relatively stable within 8-12 weeks and does not significantly change in the short term, so repeated testing has limited significance. However, the hospital conducted multiple “glycated hemoglobin” tests for short-term inpatients during a single hospitalization. Another example is that both “C-reactive protein” and “high-sensitivity C-reactive protein” can assess the degree of infection, with basically the same clinical significance, and generally, one is selected for testing as needed. However, the hospital conducted both tests simultaneously for a large number of patients. These actions are akin to measuring height multiple times in one day using various methods, with little clinical value and wasting medical resources. Similar issues existed in various genetic testing, fecal parasite egg collection and microscopic examination, red blood cell antibody screening, hepatitis B and C testing, etc., involving costs of 5.355 million yuan.
– Unbundling charges. For example, when conducting a full abdominal CT scan, the hospital should charge for one “full abdominal CT plain scan.” However, when conducting such scans, the hospital charged for three plain scans of the upper, middle, and lower abdomen, with the total cost of the three scans exceeding the cost of one “full abdominal CT plain scan.” Similar issues existed in procedures such as intestinal adhesion lysis and breast segment resection, involving costs of 1.924 million yuan.
The hospital also had other illegal and irregular issues.
2. The First People’s Hospital of Jiujiang City, Jiangxi Province. Upon investigation, the hospital had 42 issues with an illegal and irregular amount of 5.928 million yuan, but the hospital only returned 19,600 yuan of medical insurance funds through self-examination and self-correction. Typical issues include:
– Overdiagnosis and overtreatment. For example, during one hospitalization, the hospital conducted four syphilis tests and three hepatitis C tests without indications, which had limited clinical significance, wasted medical resources, and harmed patients’ health.
– Overcharging. For instance, corneal curvature measurement, intraocular lens power measurement, and retinal laser photocoagulation were charged per “session.” One patient should be charged once for one measurement or treatment. However, the hospital arbitrarily exceeded standard charges, with some patients being charged once for the left eye and once for the right eye, or being charged 3-4 times. Similar issues existed in projects such as pneumatic therapy and color Doppler ultrasound, involving costs of 820,000 yuan.
– Duplicate charging. Spinal nerve root lysis and laminectomy decompression are procedural operations in intervertebral fusion cage implantation and bone fusion surgery, and the related costs are already included in the price of “intervertebral fusion cage implantation and bone fusion surgery,” so no additional charges should be imposed. However, when the hospital conducted intervertebral fusion cage implantation and bone fusion surgery, it not only charged the corresponding fee but also repeatedly charged for spinal and nerve root adhesion lysis and decompression. This is akin to a computer repair service not only charging for the repair but also for turning on and logging into the computer. Similar issues existed in interventional therapy and hemodialysis, involving costs of 2.148 million yuan.
The hospital also had other illegal and irregular issues.
3. Changchun Hospital of Traditional Chinese Medicine, Jilin Province. Upon investigation, the hospital had 38 issues with an illegal and irregular amount of 16.387 million yuan, but the hospital only returned 1.201 million yuan of medical insurance funds through self-examination and self-correction. Typical issues include:
– Overcharging. For example, “bone mineral density measurement” should be charged per “measurement session,” but the hospital charged based on the actual measurement site, with multiple charges for a single measurement at different sites such as the lumbar spine, hip, and forearm. Another example is that “small needle-knife therapy” should be charged per “treatment site,” but the hospital charged based on “needle entry points, acupoint reaction points, and pain points.” For a patient receiving treatment at two sites (neck and waist), the billing list charged 23 times based on pain points. Similar issues existed in pathological diagnosis and B-ultrasound examination, involving costs of 4.407 million yuan.
– Overdiagnosis and overtreatment. For some patients in the hospital, on the same day, one potassium, sodium, and chloride value measurement was conducted through the “blood gas analysis” test package, and another measurement was conducted through the “blood biochemistry” test package. The two measurements had similar values and limited clinical significance. Similar issues existed in the rapid plasma reagin test, involving costs of 1.875 million yuan.
– Duplicate charging. Endotracheal intubation is a procedural step in some general anesthesia operations, and its cost is already included in the price of “general anesthesia,” so no additional charges should be imposed. The hospital charged for “general anesthesia” when conducting general anesthesia but still charged for “endotracheal intubation,” which is a repeated and excessive charge. Similar issues existed in interventional therapy, catheterization, and other projects, involving costs of 555,000 yuan.
The hospital also had other illegal and irregular issues.
4. Shijiazhuang People’s Hospital, Hebei Province. Upon investigation, the hospital had 86 issues with an illegal and irregular amount of 20.009 million yuan, but the hospital only returned 1.082 million yuan of medical insurance funds through self-examination and self-correction. Typical issues include:
– Overdiagnosis and overtreatment. Follicle-stimulating hormone, luteinizing hormone, prolactin, estradiol, progesterone, testosterone, and human chorionic gonadotropin measurements are mainly used as diagnostic bases for pubertal development indicators, normal pregnancy diagnosis, abnormal pregnancy monitoring, and male reproductive disorders. However, the hospital conducted these sex hormone tests for over 2,500 patients aged 60 and above, which had almost no clinical significance. Similar issues existed in projects such as thyroxine and carcinoembryonic antigen testing, involving costs of 1.118 million yuan.
– Overcharging. For example, “dressing change” should be charged in four grades based on wound size: small, medium, large, and extra-large dressing changes. Among them, large dressing changes are generally used for infected wounds, wounds with 11-30 sutures, or wounds with a length greater than 5 centimeters. The hospital conducted minimally invasive laparoscopic surgeries with small wounds but charged for “large dressing changes” after the surgery. This is akin to a consumer purchasing a small bottle of mineral water but being charged for a bottled water. Similar issues existed in tumor antigen measurement and oxygen inhalation, involving costs of 3.472 million yuan.
– Duplicate charging. For instance, “coronary rotational atherectomy” refers to using a high-speed rotating head to grind atherosclerotic plaques and calcified tissues in the coronary arteries into particles, eliminating plaques blocking the vascular lumen, and thereby treating coronary heart disease. According to regulations, the cost of postoperative stent placement is already included in the price of “coronary rotational atherectomy,” and no additional charges should be imposed. However, the hospital violated regulations by repeatedly and excessively charging for stent placement. This is akin to a