B-ultrasound, CT, magnetic resonance is the most familiar examination items, but medical imaging examination is also the “hardest hit area” of defrauding medical insurance funds. Like the recent investigation of the Wuxi Hongqiao Hospital fraud case, the brazenness of the criminals’ inspection fraud is shocking.
Let’s take a look at the various fraud methods used by criminals.Falsified image checks. Jiangsu Wuxi Hongqiao Hospital copied and intercepted images of other patients corresponding to diagnosis directly from the image report database such as ultrasound, manually modified the report value, forged corresponding CT, MRI, ultrasound and other report records, and fabricated diagnosis and treatment services.
Yufeng Hospital of Zhengzhou Guancheng is suspected of forging examination reports such as color ultrasound and X-ray photography. The serial number, image and content of color ultrasound reports collected at different times are completely consistent, and the collection time of color ultrasound images for different patients is completely the same. The X-ray report does not match the examination site shown in the image, such as the chest reported and the hand shown in the image.
The check items are inflated. Fushun West Hospital of Zigong City, Sichuan Province carried out CT plain scan, and charged the fees of “spiral CT plain scan” and “X-ray computed tomography (CT) imaging” at the same time, but did not actually carry out CT imaging processing. Inflated inspection items in an attempt to pass.
Fabricate the inspection report. Harbin Shangzhijianheng Hospital B-ultrasound report, some patients in addition to the name and other basic information, the rest of the report (such as images, descriptions, diagnosis, etc.) are blank. The health center of Wanshou Town, Quxian County, Dazhou City, Sichuan, reused 26 color ultrasound images 608 times, resulting in the same images and report contents of some patients. Shenyang Linji Hospital of Traditional Chinese Medicine took “empty film”, the image image only radiation bed or head pillow, but no human body.
Why do image fraud and insurance fraud persist?The reason is that the cost of image counterfeiting is low, the profit is large, and it is not easy to be detected.How to cut off these black hands to the health insurance fund? The devil is one foot high, and the cloud on the image is coming out.
“Image on the cloud” means that various medical institutions upload image data to the cloud to achieve centralized storage, management and sharing of data. From the perspective of medical insurance fund supervision, “image on the cloud” can effectively identify improper behavior in the use of medical insurance funds through intelligent analysis of medical image data to ensure fund safety.
In the past, traditional supervision mainly relied on manual spot checks, reporting clues, etc., and usually dealt with problems after they occurred. After the image is uploaded to the cloud, the medical insurance department does not need to arrive at the scene of the medical institution, can access the data in real time, and can quickly analyze and compare a large number of image data and diagnosis and treatment information in the cloud, and timely find violations such as “different names of the same piece”, “different pieces with the same name”, frequent inspection, and excessive diagnosis and treatment, which greatly improves the regulatory efficiency.
At the same time, patients can also check their own examination results through mobile phones in time, the first time to find false examination, fake examination and other abnormal conditions, medical institutions can not destroy image records, delete or shield image data to destroy relevant evidence.
Recently, the National Medical Insurance Administration issued the “Radiological Examination Price Project Guidelines (Trial)”, which clearly includes digital image processing and uploading cloud storage into the price composition of radiological examination; Physical film is removed from the price structure of the project and is purchased by patients on demand.
The NHC and seven other departments issued the Guiding Opinions on Further Promoting the Mutual Recognition of Inspection Results of Medical Institutions to further regulate the behavior of medical inspection and inspection.
After the “image on the cloud”, with the help of intelligent means such as big data and cloud storage, the supervision of medical insurance funds has shifted from passive to active, fundamentally solving the problems of “repeated inspection, repeated inspection, multiple inspection” and so on that have been criticized for a long time, and the situation that simple “copy and paste” and “Zhang Guanli Dai” can defrauding medical insurance funds in the past will be gone forever.
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