Recently, a young man in his 20s, Li, was admitted to a hospital in Renshou County, Meishan City due to illness. Surprisingly, the medical insurance department found that when the hospital bill was reviewed, the inspection items were arranged with items such as “prenatal routine examinationâ€, “vaginal secretion examination†and “fetal heart monitoring†that only female patients can happen!
This "inverted yin and yang" bill was extracted from the intelligent audit system known as the "Eagle Eye".
Two months ago, the Meishan Medical Insurance Bureau officially launched the intelligent audit system to review the medical insurance reimbursement documents. This system changed the status quo of the extensive review of medical insurance audits relying on manual sampling, and achieved 100% no-detail fine review of all medical documents. Through the comprehensive review of tens of thousands of medical expenses documents, some non-compliant medical treatments such as repeated medications, package-type examinations, and violations of age and sex restrictions have been effectively curbed, and the safety of medical insurance funds has been effectively protected.
The safety of the medical insurance fund is related to the vital interests of each insured. Compared with the well-established medical insurance supervision system, the intelligent review of the medical insurance fund in the era of big data is an important and indispensable part.
The reporter learned from the People's Social Welfare Office that in addition to Meishan, Chengdu, Ziyang, Leshan, Panzhihua, Suining and other cities and provinces at the same level, the medical insurance has gradually realized the intelligent review and supervision of medical insurance funds.
A manual check and review in front of big data is like "pediatrics"
Wang Laohan’s medical insurance reimbursement documents in a health center in Meishan City were found by the intelligent audit system to be in violation of two rules: one was directly used by doctors to use the second-line medication for “injection with doxofyllineâ€, which violated the rules of ladder medication, and required reimbursement for doctors. Provide the basis for medication; second, Wang Laohan is a male, but his inspection program has a "vaginal irrigation" project for female patients...
Liao Po, who is in her 70s, lived in a hospital in Renshou. The doctor prescribed two drugs, “bromohexine hydrochloride tablets†and “amyl bromide hydrochloride oral solutionâ€. These two drugs are all the same as the viscous phlegm-dissolving drug. According to the medical insurance reimbursement, the drug under the same classification item should not be superimposed and used, and it is a repeated drug. What is even more puzzling is that the medical receipts sent by the hospital to the medical insurance department show that after two days of discharge, Liao’s mother is still producing various medical expenses...
Limited gender examination, repeated medication, overdose medication... The various non-compliant medical behaviors exposed since the trial operation of the intelligent audit system made Chen Jianming, director of the Meishan Medical Insurance Bureau, deeply aware of the urgent and important promotion of medical insurance intelligence audit under the current situation.
Up to now, there are more than 2,000 designated medical hospitals, clinics and pharmacies in Meishan City. With the expansion of medical insurance coverage, the number of people enjoying treatment has soared, more and more medical institutions have been appointed, and the disadvantages of inadequate medical supervision and supervision and backwardness of regulatory methods have become increasingly apparent. In September last year, Meishan City Medical Insurance Bureau began trial operation of the medical insurance intelligent audit system, and officially launched in April this year, exploring the intelligent supervision of medical services for designated medical institutions, and strengthening the risk of prevention and control of medical insurance funds.
“In the past, the risk prevention and control of medical insurance funds was mainly manual spot check, and the proportion of spot checks was less than 20%. Intelligent supervision changed this situation.†Chen Jianming introduced that the intelligent audit system can realize the uploading of fixed-point medical institutions and designated pharmacies based on the audit rules. The medical insurance-related settlement data is 100% audited, mainly including drugs, medical treatment projects, inspection items, medical materials, medical treatment behaviors, etc., to achieve standardized, intelligent and refined medical insurance audit work, and promote the more standardized and rational use of medical insurance funds.
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