The Implementation Opinions on Strengthening the Normalized Supervision of the Use of Medical Security Funds has been deliberated and adopted by the executive meeting of the State Council and issued recently. On the afternoon of June 9, the Information Office of the State Council held a regular briefing on the policies of the State Council to introduce the situation of strengthening the normalization of supervision of the use of medical security funds. What measures will be taken to strengthen the normalization of the use of medical security funds? Let's take a look together——
Q
What effective measures has the medical insurance department taken to normalize the supervision of the medical insurance fund?
A
Specifically, it can be summarized as "three combinations" and "five normalizations".
The first is to combine points, lines and surfaces to promote the normalization of flight inspections, special rectifications and daily supervision. Among them, flight inspection focuses on points, special rectification focuses on lines, and daily supervision focuses on areas, which are organically combined and complement each other. Through the combination of points, lines and surfaces, we strive to check one, investigate thoroughly, and standardize one, so as to systematically promote the supervision of medical insurance funds.
The second is the combination of on-site and off-site to promote the normalization of intelligent monitoring. Medical insurance fund supervision objects are many, difficult, relatively insufficient regulatory forces, on-site inspections are difficult to timely and effective wide coverage, which requires innovative ideas and methods, the use of modern information technology to seek solutions, and the use of new technology to empower. In this regard, intelligent monitoring of medical insurance is one of the important measures to solve the pain points and difficulties of supervision. Through the promotion and application of intelligent monitoring, the whole process of hospital front-end reminder, end-of-office audit, and post-administrative supervision can be realized.
The third is to combine government supervision and social supervision to promote the normalization of social supervision. Continuously improve the social supervision system, unblock channels for reporting and complaints, and comprehensively advance the implementation of the reporting reward system. As of April this year, a total of 255,000 typical cases have been exposed nationwide, sending a strong signal to severely crack down on fraud and insurance fraud with a zero-tolerance attitude, and achieving a good warning and deterrent effect. Next, in accordance with the requirements of the Opinions, we will strengthen social coordination and co-governance, make good use of the two mechanisms of reporting complaints and publicity and exposure, and build a people's defense line for the supervision of medical insurance funds.
Q
In terms of carrying out the special rectification work to combat fraud and insurance fraud, what are the priorities of the National Health Insurance Administration this year? What's different compared to the past?
A
The first is to focus on key areas such as orthopedics, blood purification, cardiovascular medicine, examination and testing, and rehabilitation physiotherapy. The second is to focus on key drugs and consumables that rank high in pharmaceutical settlement costs. The third is to focus on key behaviors such as false medical treatment and resale of medical insurance drugs, and also put forward work requirements for high-incidence violations of laws and regulations that are prone to occur after the implementation of the policy of long-distance medical treatment and outpatient coordination.
Compared with the previous work, this special rectification work has two outstanding features: first, it strengthens departmental coordination, further clarifies and refines the responsibilities of medical insurance, public security organs and health departments, and invites procuratorial organs and financial departments for the first time to join the special rectification work to combat fraud and insurance fraud in the field of medical insurance, and the situation of comprehensive supervision of the five departments has initially taken shape, laying the foundation for the in-depth development of the special rectification work. The second is to pay more attention to big data supervision. In 2023, the National Health Insurance Administration will focus on big data supervision, carry out big data supervision pilots, promote the establishment of a number of anti-fraud big data models in key areas by strengthening the application of existing medical insurance anti-fraud big data models, and gradually build a new regulatory model that organically combines off-site supervision and on-site supervision, and promote the improvement of medical insurance fund supervision capabilities.
Q
How does the National Health Commission regulate the behavior of medical services and the charging and billing behavior of medical institutions?
A
First, continue to improve the standardization of medical services. Continuously improve the standardized system of medical services by continuously improving the relevant rules and regulations of medical management, formulating and revising disease diagnosis and treatment guidelines, technical operation procedures and clinical pathways for related diseases. Revised and promulgated the Nine Guidelines for the Honest Practice of Staff of Medical Institutions.
Second, strengthen the internal control management of medical institutions. Continue to implement the Opinions of the General Office of the State Council on Promoting the High-quality Development of Public Hospitals, and continuously improve the system and norms of internal control management of medical institutions, especially the management norms of medical service price behavior.
Third, strengthen education, training and motivation guidance. Continue to strengthen medical insurance popularization education and training on relevant medical insurance regulations, and raise the awareness of medical institutions and medical personnel on the rational use of medical insurance funds.
Fourth, improve the monitoring and supervision management system. Establish a national monitoring system to monitor medical quality indicators, clinical pathway applications, clinical rational drug use, and key monitoring of the clinical use of drugs. Include the regulation of medical service behavior in the content of regular verification of medical institutions' practice licenses, into the content of regular assessment of physicians, and also in the inspection of large hospitals, to strengthen supervision and management. At the same time, we will continue to promote the construction of industry style and medical ethics, strengthen the supervision of the use of medical insurance funds, rectify fraud and insurance fraud, etc. into the key points of work to correct unhealthy tendencies in the field of pharmaceutical purchase and sales and medical services, and severely punish violations of laws and regulations in accordance with laws and regulations. At the same time, highlight key points, carry out special actions such as special treatment of unreasonable medical examinations and "private hospital management year", and focus on investigating and focusing on rectifying unreasonable use of medical insurance funds by medical institutions.
Q
How do public security organs crack down on illegal and criminal activities of defrauding medical insurance funds?
A
In accordance with the requirements of strengthening the normalization of medical insurance supervision, public security organs have cracked down on illegal and criminal activities of defrauding medical insurance funds, strengthened the connection between executions before, during, and after the event, and resolutely safeguarded the security of the national medical insurance fund. The first is to maintain a high-pressure and strike down posture, maintain zero tolerance for illegal crimes of defrauding medical insurance funds, file and investigate one case when one is discovered, focus on punishing gang organizers and professional insurance fraudsters, and make every effort to recover stolen money and stolen goods, and recover the losses of the national medical insurance fund to the greatest extent. The second is to strengthen departmental linkage, and the public security organs will continue to jointly carry out special crackdowns and rectifications with medical insurance, health and other departments, and effectively enhance the joint force of crackdowns and rectifications. The third is to comprehensively strengthen publicity and guidance, promptly expose a number of typical cases through the news media, expose their criminal methods, form a warning and deterrent, educate and guide the masses to know and abide by the law, make good use of medical insurance funds in accordance with the law, and effectively protect legitimate rights and interests.
Q
How will the National Health Insurance Administration implement the requirements of the Implementation Opinions on Strengthening the Normalization of the Use of Medical Security Funds, and effectively protect the people's "medical money" and "life-saving money"?
A
In 2023, the National Health Insurance Administration will resolutely implement the requirements of the Opinions, continuously consolidate the regulatory responsibilities of all parties, effectively strengthen the normalization of supervision of the use of medical insurance funds, comprehensively use various regulatory methods such as flight inspection and special rectification, severely crack down on all kinds of illegal acts of fraud and insurance fraud with a zero-tolerance attitude, and resolutely guard the bottom line of medical insurance fund safety. At the same time, we will further implement the requirements of the Opinions from the following aspects.
The first is to promote intelligent monitoring and do practical and meticulous. Research and issue the Notice on Comprehensively Promoting the Intelligent Review and Monitoring of Medical Security Funds, and initially realize the "one network" of intelligent monitoring nationwide.
The second is to further strengthen administration according to law. On the basis of systematically summarizing the implementation of the Regulations on the Supervision and Administration of the Use of Medical Security Funds, we are studying the implementation rules of the Regulations and further detailing some of the principled and authorized provisions in the Regulations.
The third is to make good use of the comprehensive evaluation system for the supervision of medical insurance funds. Effectively play the role of the "baton" of comprehensive evaluation.
Fourth, strengthen policy publicity. Make good use of both positive and negative examples, and severely punish negative examples of illegal use of medical insurance funds, promptly expose them, and give play to the role of warning and deterrence; For advanced models of compliant use of medical insurance funds, it is necessary to increase positive publicity and give play to the role of positive incentives.
Source: Chinese government website