How to strengthen the review of medical insurance expenses and ensure the safety of medical insurance funds
Abstract: With the continuous growth of social economy, at this stage, China#39;s medical service.The level of service has also been significantly improved, and medical insurance expenditure has been increasing year by year. In the current medical institutions, there are large inspections, large prescriptions, and arbitrary charges.Standardize the medical behavior of the hospital and fundamentally guarantee the legal rights of the insured.Benefit, and to achieve the balance and safety of the medical insurance fund, must be on the current medical.The cost review work is being improved and innovated. Based on this, the article is mainly to strengthen.The examination of medical insurance expenses and the effective ways to ensure the safety of medical insurance funds were explored.
Key words:medical service level; medical insurance fee review; family bed; outpatient service; major illness
Health care is closely related to the daily lives of the people, and China is in the past
For a long period of time, there are problems of “seeing a doctor” and “difficult to see a doctor”.In order to reverse the above situation and improve the quality of medical services, the medical insurance system shouldborn to the sea. In recent years, the coverage of medical insurance has become wider and wider, and its related systems have also constantly improving. However, in practice, it is often in the medical insurance cost review process.Problems have arisen, which in turn has a serious impact on the safety of the health care fund. based onTherefore, it is necessary to establish a sound and feasible medical insurance fee review mechanism to better solve the above problem.
Medical insurance is a measure of the cost of medical care to compensate for the risk of illness or accident. The implementation of the medical insurance system has played an important role in safeguarding the health of the people and promoting the development of health. However, due to interest-driven, institutional loopholes and other reasons, various types of medical insurance fraud have followed, seriously affecting the safe operation of medical insurance funds, and social harm is extremely great.
The main implementer of health insurance fraud
Due to the different medical insurance systems at home and abroad, the main body of implementing medical insurance fraud is different. In all cases at home and abroad, the distribution characteristics of medical institutions, doctors and pharmacies are large. However, the most domestically implemented fraudulent entities are designated medical institutions. Hospitals and clinics use their positions to organize doctors and nurses to use legal and institutional loopholes to swindle insurance or obtain medical insurance. Cash is the worst in all medical insurance fraud subjects. The foreign fraudsters are medical device providers and other medical insurance providers. Medical device providers, including pharmaceutical companies and medical device manufacturers, often give rebates to bribe the attending doctors and let doctors recommend them to patients. The hospital, drug or service, because the way of giving kickbacks will affect the doctor#39;s diagnosis and treatment of patients, is considered fraud in the United States, other medical insurance providers also conspired to defraud the health insurance fund by giving patients kickbacks.
The role of medical institutions and their staff in the process of fraud is very obvious, because they participate in the diagnosis of patients#39; illnesses, prescriptions and the issuance of invoices. Other fraudulent subjects often get connivance and cooperation from the staff of medical institutions when they commit fraud. Regardless of the type of fraud in which the fraudulent implementation entity is fraudulent, it is in the form of a medical insurance fund for fraudulent insured persons, which jeopardizes the life-saving money of the insured.
Primary fraud
Medicare fraud mainly includes illegal treatment, falsification of prescriptions or bills, hospitalization or medical treatment, and the use or misappropriation of funds in the name of falsehood. Violation of treatment. Violation treatment includes threeperformancesform.
The first is over-medical, that is, the doctor cooperates with the patient, repeats, over-prescribes the drug, and then resells the drug for profit. The second type is to prescribe drugs that do not meet the medical condition, that is, the doctors should open the non-medical insurance list drugs or special effects drugs to the patients in the course of treatment, so that the patients can be reimbursed. The third type is for doctors and patients to jointly issue false medical insurance payment items or medical services. For example, the non-medical insurance payment types (such as car accidents, work injuries, fights, etc.) are changed to medical insurance to pay for the disease type, and the medical insurance pays for the disease type declaration. The project is recorded in the catalogue, and the patient is issued a false receipt to defraud the medical insurance fund. In the 2011 US Health Insurance Fraud and Abuse Control (HCFAC) report, a Miami nurse repeatedly conducted unnecessary medical tests on patients to defraud the Medicare fund of $230,000.
Forging prescriptions or tickets. Regardless of who the implementation is, the use of false prescriptions or bills to forge, expand medical expenses to form the evidence of insurance reimbursement, is the most direct form of medical insurance fraud.Apply or misappropriate funds in the name of falsehood. In China#39;s medical insurance system, the financing of the medical insurance fund is paid by the individual and the unit, or the individual and the government jointly contribute, and then
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