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Taking the lead, the National Health Insurance Administration issued an important announcement: "Take control of the pen in the hands of doctors!" ”
The official website of the National Health Insurance Administration released an important announcement this afternoon (October 8), and the deadline for soliciting comments is from now until 17:00 on October 17, 2023.
According to the Draft for Comments, the subject of medical insurance supervision will be extended from medical institutions to medical personnel, and those responsible for intentional fraud and insurance fraud involving the use of medical security funds will face measures such as suspending medical services and suspending or terminating medical insurance settlement agreements.
This has attracted a lot of attention, and people have begun to think, is it really necessary to closely manage the pen in the doctor's hand, or is it a temporary transitional measure?
The industry has long called for strengthening the management of medical insurance physicians.
As early as 2018, Dai Xiuying, a member of the National Committee of the Chinese People's Political Consultative Conference, put forward a proposal at the two sessions, suggesting the establishment of a national medical insurance physician system as soon as possible. She believes that doctors have the lead in making decisions about treatment, whether it is the method of treatment, examination items, treatment plan or medication selection. Due to the problem of medical professionalism and information asymmetry, patients have little choice in the diagnosis and treatment of their own diseases, and it is completely up to the doctor to decide. If you want to control the rapid growth of medical costs, doctors need to properly manage the "pen" in their hands, that is, to establish a sound medical insurance physician management system.
The management of medical insurance payment qualifications is an effective way for medical insurance physicians to manage, which is also one of the fund management methods widely used in various countries internationally. This is of great significance for improving the supervision system of hospitals, standardizing the medical behavior of medical staff, urging them to truly become the "front-line guardians" of medical insurance funds, and then improving the management level of hospitals, helping hospitals give full play to the role of medical insurance policies, and protecting the legitimate rights and interests of patients to the greatest extent.
So, how to properly control this "pen"? The key is to put responsibility on the individual.
The health insurance sector is responsible for managing medical services through payment, and the existing health insurance management measures rarely concern individual medical personnel. For those medical personnel who violent, break the law or even defraud insurance, existing penalties are often imposed through cooperation between departments and other means. Although the Regulations on the Supervision and Administration of the Use of Medical Security Funds issued by the National Health Insurance Administration in 2021 stipulate the punishment methods for designated medical institutions to violate laws and regulations and illegally use medical insurance funds, it is not clear how to deal with medical insurance for the first person responsible for violations of laws and regulations, medical personnel themselves. In other words, under this circumstance, the formulation of the draft for comments can fill the gap in medical insurance for physician management and become a concrete embodiment of the refined management of medical insurance.
In addition, the draft for comments is also a specific implementation of various relevant provisions previously issued by the state: the Guiding Opinions of the General Office of the State Council on Promoting the Reform of the Regulatory System of Medical Security Funds and the Implementation Opinions of the General Office of the State Council on Strengthening the Normalization of the Use of Medical Security Funds propose to strengthen the supervision of medical service behaviors and medical expenses included in the scope of medical insurance payment, emphasize the responsibility of designated medical institutions for self-management, and establish a credit management system. and suspend the eligibility of relevant responsible persons for medical insurance payment in the medical insurance agreement. Regulations such as the Regulations on the Supervision and Administration of the Use of Medical Security Funds, the Interim Measures for the Designated Administration of Medical Security in Medical Institutions and the Interim Measures for the Designated Administration of Medical Security in Retail Pharmacies extend the objects of supervision to medical personnel, and clarify the means of suspending the medical insurance agreements of relevant responsible personnel to deal with the medical services used by the medical security funds, and suspending or terminating medical insurance settlement. It is undeniable that managing the pen in the doctor's hand is extremely necessary from a legal, emotional and rational point of view. The management targets of this consultation draft include physicians and pharmacists. According to the Draft for Comments, the management objects of medical insurance payment qualifications are relevant personnel involved in the use of medical security funds in designated medical institutions, mainly including two categories: first, health professionals and technicians such as medical, pharmacy, nursing and technical personnel who provide medical services to the insured; The second is pharmacists who provide medical services for the insured using fund settlement, including licensed pharmacists and Chinese medicine practitioners.
For designated medical institutions that violate the service agreement, they can deal with the relevant responsible personnel in accordance with the service agreement on the basis of the agreement processing, and suspend or terminate their medical insurance payment qualifications and fee settlement. To put it simply, it is to cancel the medical insurance settlement of illegal doctors and pharmacists, and the prescriptions they issue will not be reimbursed by medical insurance, and patients need to pay for themselves. In the case of medical insurance covering most of the medical costs, this can be described as a severe blow to medical insurance, they believe that patients will be more inclined to choose doctors and pharmacists who can enjoy medical insurance reimbursement for the sake of economic factors, so as to promote medical insurance doctors to more standardized and reasonable diagnosis and treatment, and maintain their medical insurance payment qualifications. In addition, the Draft also clearly stipulates that relevant personnel can obtain medical insurance payment qualifications according to the service agreement signed with the medical security handling institution, provide medical services to the insured, and be included in the scope of medical insurance supervision. Another thing is that when the medical institution and the health insurance department reach an agreement, doctors and pharmacists are automatically eligible for health insurance payment and are regulated by health insurance. Isn't that good news? Perhaps some doctors and pharmacist friends do not understand, they think that this is just putting a "shackle" on themselves.
But in fact, the purpose of this practice is to crack down on criminals who use their power to defraud insurance fraud, so as to make the medical industry clearer. We must acknowledge that some medical professionals are tempted by financial gain to use their position to profit from it, and this happens from time to time, not only when it comes to basic health insurance, but also in commercial insurance. Let's look at a few cases: In January 2022, the China Judgment Document Network and the Anhui Insurance Industry Association released details of a major illness insurance fraud case in which the main culprit turned out to be a doctor from a public tertiary hospital. Ming Moumou, as the attending physician of the second department of neurology of the South Hospital of Bozhou People's Hospital, took advantage of his position to use patients in his own department or instruct relatives and friends to disguise themselves as patients to be hospitalized, and during the hospitalization, the fictional patient suffered from acute myocardial infarction, and the fictional case applied to the insurance company for major illness insurance claims. After investigation, they have found a total of 7 cases of the gang, of which the maximum amount of a single case reached 680,000 yuan. As the main offender, Ming was sentenced to nine years and six months in prison, fined 100,000 yuan, and ordered to return illegal gains for the crime of insurance fraud.
In April this year, an insurance company in Lanzhou reported that when the company's claim center reviewed 21 claim cases, it found that Tian Moumou and Liang, doctors at a certain hospital, conspired with others to defraud insurance money many times by means of fictitious hospitalization information, forged cases and false settlement bills, and had been found to have defrauded insurance premiums of more than 340,000 yuan.
After investigation, since 2019, the suspects Tian Moumou and Liang Moumou have taken advantage of loopholes in the management of private hospitals, using the identities of assistant presidents, physicians and pharmacy supervisors to declare insurance claims by forging inpatient medical records, settlement basis, and impersonating hospitalization for the purpose of illegal profit, repeatedly seeking personal benefits for colleagues and friends, and obtaining benefit fees from them. At present, the two suspects have been arrested and fully compensated for the loss of 410,000 yuan, and the case is still under further investigation.
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Regarding the "accidental injury" that people are worried about, there are also relevant provisions in the Draft for Comments, that is, to unblock channels for objection appeals and remedies: medical security handling institutions at all levels shall set up unimpeded channels for objections and appeals to accept the appeals and defenses of designated medical institutions that raise objections to the scoring results and registration status of relevant personnel of the institution. Yang Zixuan Liu Xinyu Editing | Source of medical insurance in China
Announcement on Strengthening the Management of Medical Insurance Payment Eligibility of Relevant Personnel in Designated Medical Institutions (Draft for Comments) Attached:
For those who break the rules and intend to cheat health insurance, it can be said that they will be severely punished, the market will eliminate them, and the people will spurn them.
This is because medical security administrative departments at all levels should unblock relief channels, handle applications for review submitted by relevant responsible personnel for objections to appeal results, and protect the legitimate rights and interests of relevant responsible personnel in accordance with the law. Therefore, on the whole, the introduction of medical insurance payment qualification management has a positive effect.
For those doctors who are law-abiding and well-treated, their work and life will not be affected by the management of health insurance payment eligibility. Because they are not afraid of shadows, they can calmly cope with this management move. For those who attempt to defraud insurance, this will encounter more obstacles and restrictions, telling them to be more cautious when filling out insurance applications, and reduce the occurrence of insurance fraud incidents. This will also help protect the safety of the medical insurance fund and retain the people's "medical money" and "life-saving money".
It should be noted that the "Guiding Opinions on Strengthening the Management of Medical Insurance Payment Eligibility of Relevant Personnel in Designated Medical Institutions (Draft for Comments)" is being publicly solicited for comments, which means that everyone's opinions and suggestions on this management measure can be listened to and adopted. We hope that this initiative can achieve better results, improve the quality of medical security, and better serve the people.
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