1. Night inspection found that inpatients were not hospitalized. At the end of July this year, staff from the Nanning Municipal Social Security Bureau discovered during a routine night inspection that 7 insured patients from a certain department of Nanning Guangji Gaofeng Hospital were registered in the social security information system.

Time is not in the hospital.

He was obviously hospitalized, why was he nowhere to be seen?

The doctor on duty explained that among the seven patients, some said the hospital environment was not good and went home to sleep, some asked for leave because of something else, and some said they went home to take a shower and change clothes.

According to the person in charge of the designated management section of the Nanning Municipal Social Security Bureau, although the hospital found various reasons to explain, patients did not need to stay in the hospital at night, which meant that the patients could go home to rest after day treatment. This was a case of admitting patients who did not meet the hospitalization conditions.

Hospitalization violations.

According to the "Interim Measures for the Management of Medical Insurance Service Physicians in Guangxi Basic Medical Insurance Designated Medical Institutions", if a medically insured physician is found to be unqualified to admit a patient to hospital, 4 points will be deducted, and the medical insurance service qualification of the physician involved will be suspended for 3 months.

The medical insurance coordinating fund will not cover the 38,000 yuan in medical expenses involved in the treatment of these seven patients.

On August 28, the reporter contacted the office of Nanning Guangji Gaofeng Hospital to learn about the situation, but the hospital did not respond.

2. Sometimes it’s the hospital that violates the rules, sometimes it’s the patient’s willfulness. The reporter learned that patients going home at night during hospitalization is not a phenomenon unique to one hospital.

Some are hospital violations, and some are because patients disobey hospital management.

According to a staff member of a top-grade hospital in Yong, each hospital will have regulations that do not allow patients to stay out overnight during hospitalization, but some patients with mild illness or who are close to home will still go out or go home privately.

Sometimes, individual doctors are accommodating.

If the patient forcibly asks to go out, or simply sneaks out on his own, the hospital has no way to force the patient and can only register and report.

Overall, this is also a management problem faced by many hospitals.

A doctor at another tertiary hospital said that the rule that inpatients cannot stay out overnight will be informed to patients upon admission and they will sign some notices.

Doctors and nurses will make ward rounds and fill in examination records as required. If they find that the patient is not in the department or hospital, they will make a record and report it to the relevant hospital departments.

Ms. Gan, a citizen, said that when she was hospitalized, she went out to eat on her own. Not long after, the nurse called her to urge her to return to the hospital. If she did not return to the hospital, the nurse could not hand over the patient to get off work.

“The medical insurance settlement and payment methods for insured patients’ inpatient treatment and outpatient treatment are different.” The person in charge of the designated management section of Nanning Municipal Social Security Bureau said that it is a violation to admit insured patients who do not meet the hospitalization conditions.

Medical insurance funds have their own rules for use. In order to ensure the safety of medical insurance funds, social security agencies will strictly investigate and deal with all types of violations.

3. Irrational use of medicines, excessive inspections, etc. are also violations. Social security agencies also face many challenges in strictly investigating violations.

For example, there are many hospitals, and it may not be possible to detect violations in time.

On the evening of August 28, the reporter visited a hospital in the Dongdong District of Nanning City and saw that a bed in a ward on the seventh floor of the hospital's inpatient building was vacant and the patient did not stay overnight.

Patients said that the patients in this bed did not come to the hospital at night and came for treatment during the day.

Staff from the Nanning Municipal Social Security Bureau said that many violations and violations were found in previous inspections.

For example, irrational use of drugs and unreasonable examinations. The examinations, medication and diagnosis performed by the hospital have nothing to do with the patient; decomposed hospitalization means that inpatients have not recovered or reached the discharge status after one hospitalization, but have been discharged and hospitalized multiple times.

, various admission and discharge examinations are repeated; handle imposter hospitalization, use other people's medical insurance information to handle hospitalization procedures and settlement for another patient, etc.

In terms of over-examination, which is a relatively hidden violation of regulations, some patients do need more examinations for further diagnosis, but medicine also has its standardized clinical path, and medical insurance doctors should provide scientific and reasonable diagnosis and treatment services in accordance with medical standards.

4. Various inspection methods ensure the safety of the fund. Medical insurance funds are "life-saving money" for insured persons, and illegal use of medical insurance funds harms the interests of insured persons.

To this end, the Nanning Municipal Social Security Bureau has also adopted a variety of methods and measures to protect the safety of medical insurance funds.

For example, designated medical institutions can be inspected through daily inspections, annual inspections, online inspections, night inspections, special inspections, joint inspections with other relevant units, and acceptance of reports and complaints.

The irregularities discovered this time at Nanning Guangji Gaofeng Hospital were discovered during routine night inspections.

Even routine inspections are not always reported in advance.

The person in charge said that many times, after determining the hospital to be inspected, the staff will contact the hospital when they arrive, and then conduct an on-site inspection and check the hospitalization list and patient hospitalization status.

In addition, the Nanning social security agency also uses an intelligent review system to provide advance reminders for prescriptions prescribed by medical insurance doctors. If the medical services or drugs prescribed by the doctor exceed the diagnosis and treatment standards or the scope of medical insurance, a prompt will pop up, and the doctor can decide to force the prescription based on the patient's condition.

Pass or give up.

Thereafter, the medical insurance agency will conduct post-facto reviews of these prescriptions to improve the quality and efficiency of supervision.