┃Source: Huang Xuejun, Jiangxi Provincial Medical Security Bureau
The audit of the medical insurance fund is an important work to promote the implementation of the national medical security policy, maintain the safety of the fund, and protect the legitimate rights and interests of the masses in medical protection. From 2020 to 2021, the National Audit Office organized a "comprehensive physical examination" of the operation and effectiveness of the basic medical insurance fund since the establishment of the national medical security system for three years, accurately pointed out the problems existing in the operation and management of the medical insurance fund, and accurately identified the "pulse" and prescribed "prescriptions" for deepening the reform and development of medical insurance and improving the ability of modern governance of medical insurance. At present, the rectification and implementation of audit feedback problems in various places has achieved important stage results. Doing a good job in the "second half of the article" of audit rectification is the proper meaning of the topic of improving the quality and effectiveness of audit supervision. From the perspective of strengthening the supervision of medical insurance funds, the author intends to talk about some personal thoughts and experiences on how to make good use of audit results.
First, based on the "examination of the disease body", give full play to the role of medical insurance fund audit in promoting fund supervision
In recent years, the national medical security system has continued to increase the supervision of medical insurance funds, and has always maintained a high-pressure situation of cracking down on fraud and insurance fraud, which has achieved a good deterrent effect, and the awareness of the safety of medical insurance funds in the whole society has become more and more intense. At the same time, with the in-depth advancement of normalized supervision, some medical insurance violations and violations are still frequent, the means are more hidden, and even some collude with each other inside and outside to form a fraudulent insurance "interest community", which brings new and greater challenges to the supervision of medical insurance funds. As an important part of the supervision system of the party and the state, auditing the medical insurance fund is not only an inevitable requirement for building a full-coverage audit work pattern, but also an important force to promote the deepening and solidification of the supervision of the medical insurance fund. The construction of a full-field, full-process fund security prevention and control mechanism is inseparable from the two-wheel drive and two-way force of audit supervision and fund supervision, give full play to the role of auditing to help supervision, and effectively build a to protect the people's life-saving money.
On the one hand, the audit found that the problem provides a target for strengthening fund supervision. Finding problems is an essential function of auditing. Judging from the problems found in the audit of the medical insurance fund, it involves many fields and links such as the raising, use, operation and management of the medical insurance fund, of which nearly half is the problem of hedging fraud, which reflects the severe situation facing the supervision of the medical insurance fund and the shortcomings and omissions. Especially since the establishment of the National Medical Security Bureau in 2018, the fight against fraud and insurance fraud has been placed in a prominent position, and a series of major inspection actions such as special governance, special rectification and flight inspection to combat fraud and insurance fraud have been continuously deployed nationwide, as well as the full coverage supervision and inspection carried out by the coordinating districts every year. This once again reminds us that strengthening the supervision of medical insurance funds cannot stop for a moment, and there can be no blind spots. Further, the problems found in the medical insurance audit have pointed out the direction for accurately promoting the supervision of the fund, and it is necessary to take the problems found in this audit as the starting point, adhere to the point of view to carry out self-examination in all fields, increase the frequency of supervision and inspection of designated medical institutions with problems, resolutely prevent the spread of problems, repeated investigations and repeated violations, and lead the fund supervision to target the force.
On the other hand, the audit supervision method brings enlightenment to optimize fund supervision. The ultimate purpose of medical insurance audit supervision and fund supervision is to standardize the use of medical insurance funds, and supervision and inspection are only means and methods. Audit supervision focuses on tracking the flow of funds, comprehensively uses methods such as correlation comparison, multi-dimensional analysis, and cluster classification to carry out "on-site audit + off-site audit", solidly promote big data audit, carry out normalized centralized research and judgment, and strive to accurately and efficiently find problems. This explores experience for deepening the reform of medical insurance fund supervision and comprehensively establishing an intelligent monitoring system, which is conducive to realizing the transformation of fund supervision from manual single audit to all-round, whole-process and full-link intelligent monitoring of big data. Especially in the fields of flight inspection and off-site medical supervision, it is urgent to rely on a centralized and unified intelligent monitoring system to promote the application of video surveillance, biometrics and other technologies, improve the intelligent monitoring function, promote the on-site inspection to go deeper and more solid, and truly let the fund supervision plug in the "wings" of modern information technology.
Second, concentrate on "curing the existing diseases" and earnestly shoulder the political responsibility for rectifying the audit feedback problems of the medical insurance fund
Doing a good job in the "second half of the article" of the medical insurance fund audit and rectification is an important political task of the medical security system, and it is also a key part of the full transformation and application of audit results. Only by "clearing" the audit feedback problem and firmly shouldering the responsibility for audit rectification, can the audit effect of the medical insurance fund be maximized. In particular, the medical insurance fund supervision front undertakes the responsibility and mission of connecting audit supervision and fund supervision, and should be brave and good at acting in audit rectification, and take solid and effective measures to make audit feedback problems "clear zero" item by item, and truly achieve rectification and reform without letting go, and problems that are not solved and not let go.
The first is to cultivate the consciousness of taking the initiative to change. This reflects the due attitude and basic position on audit rectification. In the process of auditing, the auditors have communicated with the audited units on some issues, and the audited units have also signed and sealed them in accordance with the regulations. This not only helps to timely "stop loss" of the medical insurance fund's "running and dripping", but also strengthens the education and guidance function of audit supervision, helping the audited unit to promote standardization in auditing and excellent service in standardization. As the leading unit for medical insurance audit and rectification, the medical insurance department needs to show responsibility and set an example in actively and actively reforming, accept the problems according to the order, do not bargain, do not prevaricate, and use practical actions to show the consciousness of facing the problem and the courage of the blade to themselves, and compact the rectification responsibility in detail.
The second is to unite the combined forces of coordinated reform. Promoting audit rectification cannot be "solo", but must be "ensemble" by all parties. The problems found in this medical insurance fund audit involve a wide range of problems and a large amount of funds, both the problems of the medical insurance department itself and the problems of departmental coordination and linkage. To complete the audit and rectification task with high quality and efficiency, it is necessary to build a linkage rectification work pattern led by the medical insurance department, coordinated by the responsible units, and contributed by all parties. For example, with regard to strengthening the supervision of designated medical institutions, medical insurance, health care, public security and other departments should, on the basis of performing their respective statutory duties, take the opportunity of rectification of audit problems, share inspection information, carry out joint law enforcement, promote the linkage of executions, and achieve the effect of "rectifying one and deterring a group"; for example, with regard to resolving the problem of duplicate insurance and repeated reimbursement, medical insurance should not only unite with public security, taxation and other departments to severely crack down on the behavior of over-reporting of one vote and even repeated reimbursement and insurance fraud with false invoices, but also jointly finance, Departments such as information construction plug the loopholes arising from the problem of duplicate insurance from the source, so that people and things that are repeatedly insured can be discovered in a timely manner, and the subsidy funds that are repeatedly allocated can be deducted in a timely manner.
The third is the courage to adhere to thorough reform. Whether the problems found by the audit can be thoroughly rectified is a major test of the government's execution and credibility. Many of the audit feedback problems are difficult and complicated diseases, there is a strong "drug resistance", there is no long-term "course of treatment" is difficult to see results, we must work for a long time, often grasp and unremittingly promote rectification. The background and causes of these problems vary widely, and the difficulty of rectification is also different, some can be changed immediately and see results, and some must be gradual and continuous. In particular, for some designated medical institutions that are prone to frequent violations of medical insurance laws and regulations, it is still necessary to manage them normally and strictly investigate them, and we must not collect money and collect troops at the first sight of results, and hope to fight a war once and for all. In addition, in the process of promoting rectification and reform, we should not scratch the itch of our boots and knock on the side, but only tinker with details and details, but should kill more "return guns" and quench a few more "back to the furnace fire", and truly achieve the results of "thorough reform" with the determination of "thorough reform".
Third, focus on "preventing diseases before they occur", and accelerate the construction of a long-term fund supervision mechanism that is compatible with normalized auditing
Auditing has a constructive role in promoting standardization and clearing the source, and cannot be limited to "checking errors and correcting defects", but also needs to pay attention to the prevention and early warning functions of hidden risks. In July this year, the National Audit Office issued the "Guiding Opinions on Improving the Effectiveness of Social Security Audit Supervision", proposing to orderly promote the full coverage of audits in the field of social security, organize and carry out tracking audits of the implementation of major policies and measures in the field of social security every year, and carry out normalized audit supervision of key funds that are of concern to the masses and have frequent problems such as medical insurance and pensions. It can be seen that the all-round and normalized audit and supervision of medical insurance funds has risen to an important institutional arrangement for maintaining the safety of funds and protecting the interests of the masses, which is highly consistent with the goals and tasks of medical insurance fund supervision under the new situation. At present, it is urgent to build a long-term fund supervision mechanism that is compatible with normalized auditing, and accelerate the formation of a fund security prevention and control pattern that integrates refined management, professional supervision and strict supervision.
First, focus on the problems found by the audit and achieve results in strengthening fine management. Whether the audit can maximize the role of early warning and "probe" is inseparable from the "deep cultivation" of the audited unit in the daily prevention and control management. For designated medical institutions and medical insurance departments, on the basis of strictly grasping audit and rectification, we must also be good at digging into the root causes through the problems revealed, and timely checking and filling in the gaps. In particular, for the phenomenon of "running and dripping" of the medical insurance fund caused by extensive management and poor internal control, it is even more necessary to firmly establish the concept of "seeking benefits from management", give full play to the strategic purchase role of medical insurance, make sufficient "embroidery efforts" in medical insurance management, promote standardized use through fine management, and get out of the strange circle of "repeated trials and repeated violations" of medical insurance violations.
The second is to take advantage of the opportunity of audit rectification and reform to make concerted efforts in promoting comprehensive supervision. Departmental linkage is not only an inevitable requirement for completing the task of audit and rectification, but also an important way to strengthen the supervision of medical insurance funds. At present, medical insurance and public security, health and other departments jointly carry out supervision and inspection, and are more and more widely used in all fields and links of medical insurance fund supervision. It is necessary to further summarize and refine the good experience of departmental coordination in this audit and rectification, solidify it into a system and mechanism for implementing comprehensive supervision, focus on in-depth linkage and efficient coordination, promote information sharing, linking criminal discipline, realize mutual assistance in inspection, mutual recognition of results, and strengthen the deterrent effect of comprehensive supervision of "shaking fingers into fists".
The third is to make suggestions against audits and seek breakthroughs in deepening regulatory reform. Modern auditing not only helps to find prominent problems that are universal, tendentious and emerging, but also deeply analyzes the institutional obstacles, mechanism defects and institutional loopholes caused by the problems, and accurately puts forward suggestions for improvement and improvement. It is necessary to accurately grasp the functional positioning of auditing to reveal problems, standardize management, prevent risks, and promote reform, give play to its role as a "catalyst" for deepening reform, and lead the supervision of medical insurance funds to improve quality and efficiency. In particular, it is necessary to attach great importance to making good use of audit results and making full use of audit recommendations, promote the effective combination of audit supervision and fund supervision, actively strive for the support of party committees and governments, promote the reform of the fund supervision system and system in line with the trend, constantly innovate regulatory methods and methods, strive to make new breakthroughs in the reform fields such as intelligent monitoring, comprehensive supervision, and credit management, and transform professional authoritative audit opinions into strong driving forces and important support for the regulatory reform of medical insurance funds as soon as possible.
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