医保基金监管

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7省部分医院违规收费等金额过亿元
第一财经· 2025-10-10 03:37
作者 | 第一财经 陈益刊 一些医院违规收费及多结算医保基金违规行为再次被审计部门发现。 近期26个省份审计部门陆续公开当地2024年度省级预算执行和其他财政收支的审计工作报告(下 称"审计报告"),其中,7个省份审计部门发现医院违规收费及多结算医保基金合计约1.5亿元。 湖南审计报告重点审计20家医院发现,有11家医院通过重复收费、分解住院、过度诊疗等方式违规 收费4684.89万元。 湖北审计报告称,8家医院采取虚计数量、以低充高、串换或拆分项目等方式,多结算医保基金 2378.23万元;6家医院采取分解住院、人为修改患者诊断结论等方式,多结算医保基金2739.01万 元。8家医院违规开展过度检查、开具"大处方"等,多收费1142.99万元;5家医院超标准多收药品及 医用耗材费用292.29万元。 河北审计报告称,在诊疗服务和收费结算方面,河北医科大学第四医院等9家公立医院存在超核定收 费标准收费、虚计药品耗材和诊疗项目数量、将已包含的项目内容另行收费、超医保确定的支付范围 申请基金结算等问题,涉及多收费1492.75万元、多结算医保基金238.27万元。 根据浙江审计报告,针对64家公立医院审计发现,3 ...
异常数据引发飞行检查,国家医保局精准查处多起典型案例
Jing Ji Guan Cha Bao· 2025-09-30 02:03
(原标题:异常数据引发飞行检查,国家医保局精准查处多起典型案例) 经济观察网 据国家医保局官网信息,依托全国统一的医保信息平台,国家医保局精准查处多起异常数 据典型案例,做到发现一起、查处一起、整改一起,医保数据对监管的赋能作用持续凸显。 神秘未知医生大量开药 常规药品数据监测发现,某名医生开具烟酰胺总金额高于全国平均水平200余倍。异常数据引起医保部 门关注,迅速组织监管力量对相应医院医保结算数据作重点筛查,发现较多疑点数据,医保基金飞检组 随即入驻。 检查发现,烟酰胺开方量异常由"数据质量塌方"造成。该院上传的部分住院费用数据,开单医生处未填 写真实医生姓名,而是在数据处理中被填充为"未知"。数据上传国家医保信息平台后,该院多位"未 知"医生汇总的烟酰胺开方量触发异常报警,暴露定点医疗机构数据填报不规范和数据校验机制缺失的 叠加问题。 高龄老人开展辅助生殖 飞检组坚持实事求是,向被检医院及当地医保部门反馈数据问题并要求整改,未作处罚。对检查发现的 其他违法违规使用医保基金问题,依法依规作出处理。 日常数据监测发现,某医院为73岁老人开展"无痛取卵",另一医院则为86岁老人开展"试管内受精"。发 现问题后, ...
有医院为73岁老人开展“无痛取卵”,为86岁老人开展“试管内受精”?国家医保局披露→
第一财经· 2025-09-29 08:42
Core Viewpoint - The article emphasizes the importance of data quality management in healthcare institutions, highlighting how improper data handling can lead to significant regulatory issues and inefficiencies in the healthcare system [3][15]. Group 1: Case Studies of Data Issues - A doctor was found to have prescribed niacinamide at a total amount over 200 times the national average, leading to an investigation that revealed data quality issues due to the use of "unknown" in place of actual doctor names [5][6]. - An elderly patient was mistakenly recorded as undergoing "painless ovum retrieval" instead of the intended "painless gastrointestinal endoscopy" due to incorrect data entry, prompting the need for improved data validation mechanisms [8][9]. - A doctor was found to have issued multiple prescriptions for semaglutide in a very short time frame, indicating potential fraudulent activity, which led to further investigation and corrective actions against the involved medical personnel [10][11]. Group 2: Data Quality Management Recommendations - The article stresses that healthcare institutions must take responsibility for data quality management, ensuring strict audits and timely corrections to prevent regulatory alerts and unnecessary inspections [15]. - It calls for the establishment of a closed-loop management system for problem detection, alerts, and resolution, leveraging technology for better monitoring and cross-verification of data [15]. - Collaboration between healthcare institutions and regulatory bodies is essential to safeguard public funds and ensure accurate data reporting [15].
73岁“无痛取卵”?86岁“试管内受精”?医保局披露多起异常数据案例
Xin Lang Cai Jing· 2025-09-29 03:07
Core Insights - The National Healthcare Security Administration (NHSA) has highlighted issues in data quality management within designated medical institutions, revealing that even minor discrepancies can trigger alerts and lead to unnecessary regulatory inspections, resulting in wasted resources for both healthcare regulation and medical institutions [5] Group 1: Data Quality Issues - A 73-year-old patient was incorrectly recorded as undergoing "painless egg retrieval" instead of a "painless gastrointestinal endoscopy" due to a data entry error [1] - An 86-year-old patient was mistakenly diagnosed with "in vitro fertilization" because of a miscommunication in the coding process, where the doctor only entered initials without verifying the dropdown options [1] - A doctor was found to have issued multiple prescriptions for the same medication within a minute for different patients, raising suspicions of falsified medical records [2] Group 2: Fraudulent Activities - A medical representative collected multiple social security cards and used them to obtain prescriptions for diabetes medications, despite the patients having no prior history of diabetes [2] - The hospital conducted a self-inspection and took disciplinary actions against the involved doctor, including suspension and performance penalties [2] Group 3: Coding Errors - A coding error led to male patients being recorded as having undergone "hysteroscopy," when they actually received "ureteroscopy" treatments, highlighting the importance of accurate coding in medical records [4] - An abnormal prescription volume of niacinamide was detected, attributed to a lack of proper identification of prescribing doctors, resulting in multiple entries under "unknown" [4]
73岁“无痛取卵”?国家医保局披露违法违规案例
Zhong Guo Xin Wen Wang· 2025-09-29 02:52
Core Insights - The National Healthcare Security Administration (NHSA) has revealed multiple cases of illegal and irregular activities in the healthcare sector, emphasizing the importance of data quality and regulatory oversight in the era of big data [1][12]. Group 1: Data Quality Issues - A doctor was found to have prescribed niacinamide at a total amount over 200 times the national average, leading to an investigation that uncovered data quality issues due to incomplete information in the hospital's records [2]. - A 73-year-old patient was mistakenly recorded as undergoing "painless egg retrieval" instead of a "painless gastrointestinal endoscopy" due to a data entry error, highlighting the need for better data validation mechanisms [3][5]. - An 86-year-old patient was incorrectly diagnosed with "in vitro fertilization" due to a similar data entry mistake, which further underscores the importance of accurate data entry in healthcare [5][6]. Group 2: Regulatory Actions - The NHSA's flying inspection team found that a doctor was involved in issuing multiple prescriptions for semaglutide in a short time frame, indicating potential fraudulent activities, which led to further investigations [7]. - The inspection revealed that a medical representative was collecting social security cards from multiple individuals to facilitate fraudulent prescriptions, prompting the hospital to take disciplinary actions against the involved doctor [7]. - An anomaly was detected where male patients were recorded as receiving hysteroscopy services due to coding errors, which triggered a regulatory alert and necessitated a review of the hospital's coding practices [8][11]. Group 3: Recommendations for Improvement - The NHSA has called for healthcare institutions to enhance their data quality management practices, emphasizing the need for strict audits and dynamic checks before data submission [12]. - It is recommended that healthcare institutions and NHSA collaborate closely to ensure accurate data entry and monitoring, thereby safeguarding public funds and improving healthcare service delivery [12].
神秘未知医生大量开药、高龄老人开展辅助生殖……国家医保局披露数据异常案例
Yang Shi Wang· 2025-09-29 02:32
神秘未知医生大量开药 常规药品数据监测发现,某名医生开具烟酰胺总金额高于全国平均水平200余倍。异常数据引起医保部门关注,迅 速组织监管力量对相应医院医保结算数据作重点筛查,发现较多疑点数据,医保基金飞检组随即入驻。 央视网消息:据国家医保局网站消息,大数据时代,任何违法违规行为都难逃"数据慧眼"。依托全国统一的医保 信息平台,国家医保局精准查处多起异常数据典型案例,做到发现一起、查处一起、整改一起,医保数据对监管 的赋能作用持续凸显。 检查发现,烟酰胺开方量异常由"数据质量塌方"造成。该院上传的部分住院费用数据,开单医生处未填写真实医 生姓名,而是在数据处理中被填充为"未知"。数据上传国家医保信息平台后,该院多位"未知"医生汇总的烟酰胺 开方量触发异常报警,暴露定点医疗机构数据填报不规范和数据校验机制缺失的叠加问题。 飞检组坚持实事求是,向被检医院及当地医保部门反馈数据问题并要求整改,未作处罚。对检查发现的其他违法 违规使用医保基金问题,依法依规作出处理。 高龄老人开展辅助生殖 日常数据监测发现,某医院为73岁老人开展"无痛取卵",另一医院则为86岁老人开展"试管内受精"。发现问题 后,医保部门当天派出人员 ...
涉生育津贴骗保、倒卖医保回流药,医保基金监管“百日行动”启动
第一财经· 2025-09-25 07:07
国家医保局今天(25日)发布《国家医疗保障局办公室关于开展医保基金管理突出问题专项整治"百日 行动"的通知》提出, 自即日起至2025年12月31日,在全国范围开展医保基金管理突出问题专项整 治"百日行动" 。 国家医保局表示,"百日行动"是医保基金管理突出问题专项整治"突击战"的重要行动安排,坚决以"零 容忍、不松劲"的较真态度和"敢啃硬骨头"的攻坚魄力, 依法依规、严查严打欺诈骗保,力争通过"百 日行动"基本肃清两定机构倒卖医保回流药违法行为。 工作重点 开展倒卖医保回流药问题全面治理 重点查处定点医药机构伪造处方、空刷套刷医保凭证、串换医保药品、诱导"回收"、诱导"冲顶消 费"、不扫码销售,以及职业开药人和参保人非法售卖医保药品等问题。 紧盯倒卖医保回流药各关键环节,将检查中发现的药品批发企业和零售药店涉嫌伪造随货同行单、伪造 票据"洗白"回流药、篡改购销记录,药贩子、卡贩子欺诈骗保等问题线索,及时移送公安、市场监 管、药监等相关部门,强化部门协同、联查联办。 开展违规超量开药问题专项核查 紧盯药品追溯码数据监测异常的开药、购药行为,结合重点监测易倒卖回流医保药品清单,重点核查远 超临床合理用量违规开药 ...
实践故事丨织密医保基金防护网
Zhong Yang Ji Wei Guo Jia Jian Wei Wang Zhan· 2025-09-16 00:29
办案不是目的,推动治理才是根本。该县纪委监委向县医保局和县卫生健康局发出纪检监察建议书,督 促扎实开展专项整治,全面排查212家定点医疗机构,指导自查自纠,重点整治过度诊疗、分解收费、 挂床住院等行为。督促将全县319个村卫生室全部接入"村医通"系统,实现城乡居民门诊统筹报销、城 镇职工个人账户刷卡等医保高频事项"结算不出村"。推动主管部门建立完善医保基金监管、医疗服务项 目价格申报等制度机制5项。 只有管住关键人、关键处,才能防止类似问题发生。该县纪委监委会同医保、卫健、市场监管、公安等 部门开展"专业+专责"联动监督,完善周会商、月调度研判机制。采取制发工作提示等方式,压实主管 部门责任,制发违法违规使用医保基金典型问题清单,及时核查高频次就诊记录、异常结算等疑点数 据,联合第三方专业机构对医院HIS系统进行数据分析。公开选聘7名社会监督员,开展医保报销、基 金监管、投诉举报等政策宣传。建成远程监控系统,将终端延伸至125家定点医药机构,动态监测医药 服务行为真实性,推动"事后查处"向"事前预防"转变。 四川省南江县纪委监委坚持系统思维,把风腐同查同治理念要求贯穿案件查办、整改纠治、警示教育等 各方面,紧 ...
医院主动退费,背后的问题仍不能放过
Nan Fang Du Shi Bao· 2025-09-07 15:04
Core Viewpoint - The recent refund announcement by Menglian County People's Hospital in Yunnan highlights the increasing scrutiny of medical institutions regarding the misuse of medical insurance funds, revealing both the hospital's proactive approach to rectify past mistakes and the underlying issues within its governance structure [2][3][4]. Group 1: Refund Announcement - Menglian County People's Hospital has initiated a refund process for patients, with amounts ranging from 0.03 yuan to 67.18 yuan, following a self-examination of its billing practices [1]. - The hospital's actions are rare in the healthcare sector, drawing significant public attention and raising questions about the integrity of medical billing practices [1]. Group 2: Background of the Incident - The refund stems from a report by the Pu'er City Medical Insurance Bureau, which identified various violations by the hospital, including excessive testing and duplicate charges, leading to a total loss of 27,883.46 yuan in medical insurance funds [2]. - The hospital has reportedly returned all misused funds and paid fines as mandated by the authorities [2]. Group 3: Regulatory Environment - The national government has intensified oversight of medical insurance fund usage, employing advanced technologies such as big data analysis and real-time monitoring to detect previously hidden violations [3]. - The proactive refund by the hospital can be seen as a response to this regulatory trend, aimed at reducing potential penalties [3]. Group 4: Governance Issues - The incident underscores significant governance failures within the hospital, as evidenced by the involvement of its leadership in serious misconduct [3]. - The hospital's focus on profit over patient care has led to a range of unethical practices, including overcharging and unnecessary medical procedures [3]. Group 5: Recommendations for Improvement - To prevent future issues, it is essential for medical institutions to establish transparent billing practices and enhance internal auditing and compliance mechanisms [4]. - The ongoing development of intelligent medical insurance supervision systems is crucial for monitoring medical practices and preventing violations [4].
两部委明确支持合理超适应证用药,商保能否解决支付难题
Di Yi Cai Jing· 2025-09-01 12:53
Core Viewpoint - The National Health Commission (NHC) has stated that off-label drug use is currently not covered by basic medical insurance, and patients must bear the associated treatment costs [1][4]. Group 1: Regulatory Framework - The NHC and the National Medical Insurance Administration (NMIA) have emphasized the need for medical institutions to strengthen the regulation of doctors' prescribing behaviors [2][4]. - Off-label drug use, defined as the use of drugs outside the approved indications, dosages, or populations, is legally supported under the Physician Law and the Drug Administration Law when no effective treatment alternatives exist and with patient consent [2][3]. Group 2: Clinical Practice and Monitoring - Experts indicate that off-label drug use is not synonymous with inappropriate use, as clinical observations often reveal new indications for existing drugs [3]. - The NHC has previously issued guidelines for comprehensive drug evaluation, focusing on safety, efficacy, economic viability, innovation, suitability, and accessibility [3]. Group 3: Insurance Coverage and Challenges - Off-label drug use is not included in the basic medical insurance payment scope, leading to potential financial burdens for patients, especially those with chronic diseases or requiring expensive treatments [4][7]. - Commercial health insurance varies in its willingness to cover off-label drug use, with many policies stipulating that reimbursement is contingent upon adherence to approved indications [7][8]. Group 4: Future Directions in Insurance - Some insurance companies are exploring innovative products that would cover off-label drug use based on clinical guidelines, indicating a potential shift in the insurance landscape [8].