How to solve the "hanging bed and hospitalization" supervision?

"Hanging bed hospitalization" is a "firm ice" in the field of supervision and verification of the medical insurance fund, and its phenomenon has a long history. The patient's "hanging bed and hospitalization" is to exchange for higher medical insurance reimbursement levels; and hospitals can increase the hospital for hospitalization, which can increase business income.

However, this behavior seriously wastes limited medical resources and medical insurance funds, and has strong universality and disguise in the practice of medical treatment. It is one of the focus of the daily supervision of the medical insurance department and the health and health department. It is also a pain point.

"Hanging bed hospitalization" is mainly manifested in the hospital for treatment in the hospital for some time (mainly in the morning). Other time (mainly in the afternoon or evening) goes home or migrant workers, which is an ordinary illegal and illegal act. What's more, medical institutions collude with individuals and apply medical insurance vouchers to forge hospitalization. This is a serious violation of regulations and laws.

After a long exploration, Xian'an District, Xianning City, Hubei Province gradually explored a method that could be summarized as "May 4th" to solve the problem of repeated ban on "hanging beds and hospitalization". Now we communicate with readers.

Clarify the "Five Elements" to ensure that it is accurate

Medical insurance inspection housing is the most basic and effective in medical insurance inspection work, but it is also the most difficult work. The basis of rectifying the "hanging bed hospitalization" is to go deep into the front line to check the house. Only by checking the house in the front line and comparing the actual hospitalization of the patient with the information such as the medical records can the behavior of "hanging bed hospitalization" be accurate. When you are in a round, you must make five clearness.

The first is to clarify the time of the rounds. Because patients are usually treated in the hospital in the morning, it is advisable to clearly clear the time or evening of the room. Randomly select one afternoon and another night of the house as a round. It should be noted that during the round -out room, it should be ensured that the normal medical order of the hospital should not be affected.

The second is to clarify the method of checkup. Following the principle of "dual random", relevant personnel of the Medical Insurance Bureau and the Medical Insurance Fund Checking Center are arranged to participate in the inspection, and a fixed -point medical institution will be selected to conduct inspections.

The third is to clarify the contents of the room. First of all, to verify whether the patient is in the hospital, the bed, and the patients who are not in the ward or the bed, the relevant information is recorded in the case during the on -site examination, and then it is processed in conjunction with other circumstances. Then, patients in bed were required to show identity information such as ID cards, medical insurance vouchers, etc., and determined whether they were hospitalized by comparison people, certificates, cards and other information. In addition, it is necessary to ask the patient's condition, admission method, catering costs, and payment of inpatient deposits, etc., comprehensively determine whether the patient's hospitalization treatment is reasonable and compliant.

The fourth is to clarify the objects and scope of the inspection. The "Hanging bed hospitalization" inspection covers the inpatient departments of all basic medical insurance medical institutions except the infection department in the jurisdiction. During the verification Essence

The fifth is to clearly determine the standard. Xian'an District stipulates in the designated medical insurance agreement that there is no actual treatment in hospitals, records of medical expenses, and medical insurance records, but only in the ward or not in the ward in the ward or other time (generally manifested as the regulations in the regulations. Most of the expenses within the time period are inspection fees or drug fees, etc.), and are identified as "hanging beds and hospitalization". For medical institutions, it is clear that when the hospital's inpatient patients in the hospital in the hospital for a single checkpoint are less than 70%, it is determined that the medical institution has a "hanging bed hospitalization" behavior. For medical insurance patients, if they are not in the ward during examination, and the hospital cannot immediately provide effective leave procedures, materials or cumulative two rounds in the hospital, and individuals who have accumulated more than 30%of the hospitals will be determined to have the behavior of "hanging bed hospitalization". Essence

Make good use of the "four measures" to ensure that it is realistic

The key to rectifying "hanging beds and hospitalization" is to deal with in accordance with laws and regulations, and violations such as "hanging bed hospitalization" and other violations of regulations shall be punished strictly in accordance with relevant regulations. According to the provisions of the medical insurance service agreement, interviews or deductions of corresponding violations of laws and regulations, and the circumstances are severely punished in accordance with the relevant terms of the "Regulations on the Supervision and Administration of Medical Security Fund" (hereinafter referred to as the "Regulations"). Essence

The first is to conduct warning interviews. The examination found that a single hospitalized patient in the bed rate was less than 50%in the bed rate, or the bed rate in the bed was less than 60%in a row. The designated medical institution shall suspend the service agreement in accordance with the Regulations.

Second, the relevant illegal expenses medical insurance fund does not pay. The medical expenses incurred in the hospitalization of patients with hanging bed medical insurance, if the medical insurance fund has been paid, the illegal expenses will be recovered; if there is no payment, all the hospitalization expenses will be deducted from the amount of reimbursement of the monthly reimbursement of the month. If the hospital hospitalization patient is less than 70%in the bed rate, the same insured person hangs the bed in a single hanging bed, and the average daily cost of the hospitalization is deducted, and the total cost of the hospitalization of the bed two times is deducted. At the same time, criticize and educate the insured.

Third, punishment according to regulations. For the loss of the medical insurance fund, in accordance with the "Regulations", a fine of 1 to 2 times at the circumstances.

The fourth is the normal public exposure. Strictly implement the "Regulations", and the typical cases of "hanging bed hospitalization" rectification are selected from the entire region to publicly expose them publicly to promote the standardization of "hanging bed hospitalization" rectification, normalization of case exposure, and regular warning education.

Improve the "three mechanisms" to ensure standing

The rectification of "hanging beds and hospitalization" is simply improving the normal and long -term mechanism. It mainly improves the three mechanisms to form a strong deterrent to medical institutions and medical insurance patients. The first is to establish a quarterly random inspection mechanism. The Qian'an District Medical Insurance Fund Checking Center is responsible for at least once a quarter. Inspectors in several groups to determine the inspection room inspection unit by drawing by draw before departure. The "Four Nobody and Two Strains" of the grass -roots and straight into the scene, directly inserted the site of the inpatient department of the designated institution, real -time video, and objective observation.

The second is to establish a centralized rectification mechanism. In May each year, the special governance operation of the "hanging bed and hospitalization" continued to be carried out in May.

The third is to establish a year -end notification mechanism. At the end of each year, the special governance of the "hanging bed and hospitalization" is summarized to form a notification material, feedback to the district health department, and notifying the designated medical institutions in the district. Through centralized rectification and daily inspections, the continuous high -pressure medical insurance fund inspection and supervision trend has gradually formed.

Since May 2019, Xian'an District has conducted 9 special rectifications of "hanging beds and hospitalization". A total of 42 medical security designated hospitals have been checked. More than 300 people, issued and rectified letters 120 times, a total of 1.51 million yuan of medical insurance funds was recovered, and the heads of 20 hospitals were discussed.

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