Recently, the National Health Insurance Administration, the Supreme People's Court, the Supreme People's Procuratorate, the Ministry of Public Security, the Ministry of Finance, and the National Health Commission jointly issued the "Notice on Carrying out Special Rectification Work on Violations of Laws and Regulations in the Medical Insurance Fund" (hereinafter referred to as the "Notice"), requiring severe crackdown on fraud and insurance fraud.
The "Notice" clarifies the focus of work -
▶ Focus on fraud and insurance fraud such as false diagnosis and treatment, false drug purchase, and resale of medical insurance drugs, and carry out severe crackdowns;
▶ Focus on key drug consumables with large amounts of medical insurance funds and abnormal changes, dynamically monitor the use of funds, and focus on investigating and punishing fraud and insurance fraud;
▶ Focus on key areas such as orthopedics, hemodialysis, cardiology, examination, testing, rehabilitation and physiotherapy, and comprehensively carry out self-examination and self-correction.
The "Notice" requires that in April 2024, all departments will complete the mobilization and deployment of the special rectification of violations of laws and regulations of the medical insurance fund, complete the comprehensive investigation of all medical service behaviors and medical service expenses that have occurred since the implementation of the "Regulations on the Supervision and Administration of the Use of Medical Security Funds" in May, and implement legislative reforms, complete the centralized rectification in November to ensure that the special rectification work has achieved practical results, and complete the summary and report in December.
Since its establishment, the National Health Insurance Administration has focused on key and difficult issues in fund supervision, and continued to promote the systematic governance of violations of laws and regulations in the field of medical insurance. In 2023, the bureau will continue to promote full-coverage supervision and inspection, deal with 32,690 people who violate laws and regulations, cooperate with the public security department to detect a total of 2,179 cases of various crimes of fraud against medical insurance funds, arrest 6,220 criminal suspects, and recover 1.14 billion yuan of medical insurance funds involved in the cases.
Full text of the Notice
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In 2024, the medical insurance fund will violate laws and regulations
Special rectification work plan
In order to implement the decisions and arrangements of the Party Central Committee and the State Council, continuously strengthen the supervision of medical insurance funds, and effectively maintain the safety of medical insurance funds, the National Health Insurance Administration, together with the Supreme People's Court, the Supreme People's Procuratorate, the Ministry of Public Security, the Ministry of Finance, and the National Health Commission, has carried out special rectification work on violations of laws and regulations in medical insurance funds nationwide, and formulated this plan.
1. General requirements
Guided by Xi Jinping Thought on Socialism with Chinese Characteristics for a New Era, fully implement the spirit of the 20th National Congress of the Communist Party of China and General Secretary Xi Jinping's important instructions on strengthening the supervision of medical insurance funds, carry out in-depth special rectification of various violations of laws and regulations in the field of medical insurance, crack down on fraud and insurance fraud, draw inferences from one case and improve the long-term mechanism, and through the combination of "immediate reform" and "long-term establishment", realize the investigation and handling of one case, one warning, and one area of governance, and promote the high-quality development of medical insurance fund supervision to a new level.
Second, the focus of work
(1) Focus on illegal and criminal acts of fraud and insurance fraud, such as false diagnosis and treatment, false drug purchases, and reselling medical insurance drugs, and carry out severe crackdowns.
(2) Focus on key drug consumables with large amounts of medical insurance funds and abnormal changes, dynamically monitor the use of funds, and focus on investigating and punishing fraud and insurance fraud.
(3) Focus on the integration of correction and treatment, comprehensively carry out self-examination and self-correction in key areas such as orthopedics, hemodialysis, cardiology, examination, testing, and rehabilitation physiotherapy, and continue to promote the rectification of problems.
3. Division of responsibilities
All departments should carry out special rectification work in accordance with their duties, coordinate regulatory resources, give full play to the joint force of supervision, and ensure the effectiveness of rectification. The medical insurance department is responsible for taking the lead in carrying out special rectification and investigating and dealing with all kinds of illegal use of medical insurance funds. The people's courts are responsible for hearing all kinds of cases of fraud and insurance fraud, and punishing the crime of insurance fraud in accordance with law. The procuratorate is responsible for reviewing arrests, reviewing and prosecuting cases of medical insurance fraud in accordance with law, and carrying out legal supervision of the handling of relevant cases, and when necessary, issuing typical cases to guide each region in standardizing case handling. The public security department is responsible for cracking down on all kinds of fraud and insurance fraud, and promptly receiving and investigating suspected criminal leads handed over by the medical insurance department. According to their duties, the financial department shall supervise the use and management of the medical insurance fund and assist in the inspection of electronic bills for medical charges. The health department is responsible for strengthening the supervision of medical institutions, standardizing medical services and charging behaviors, actively handling clues related to medical behaviors handed over by the medical insurance department, and dealing with violations of medical institutions and related personnel.
Fourth, work measures
(1) Persist in blending leniency with severity, and dispose of it in accordance with law. We have always maintained a high-pressure posture against illegal and criminal acts such as fraud and insurance fraud, focusing on cracking down on behind-the-scenes organizers and professional insurance fraudsters who play a major role in organizing, instigating, and instigating crimes. For general violations of laws and regulations, pay attention to strengthening the connection between agreement handling and administrative punishment, and continue to promote the rectification of problems. Carry out in-depth self-examination and self-correction, and the National Health Insurance Bureau will formulate and issue a list of problems in key areas such as orthopedics, hemodialysis, cardiology, examination, inspection, rehabilitation and physiotherapy, and all localities should supervise and guide designated medical institutions to carry out self-examination and self-correction. The above-mentioned six areas should be the focus of national unannounced inspections, provincial-level unannounced inspections, and city-level cross-inspections should be the focus of inspections, and those who fail to make corrections through self-examination and self-correction or who are repeatedly investigated and recidivist should be severely dealt with in accordance with laws and regulations.
(2) Adhere to integrity and innovation, and strengthen data empowerment. Summarize and improve traditional supervision methods such as on-site inspections, make good use of inspection guidelines and typical cases, and improve the level of legalization, standardization, and professionalism of supervision. Give full play to the role of verified and effective big data models to achieve normalized screening. Combined with the pilot work of medical insurance anti-fraud big data supervision and application, strengthen the application of drug traceability codes in the supervision of medical insurance funds, explore the construction of multi-dimensional big data models, screen and analyze suspicious clues in hidden data, and promote breakthroughs in big data supervision.
(3) Persist in departmental coordination and give play to the joint force of supervision. The medical insurance department should continue to improve the communication and consultation mechanism with the people's courts and procuratorial organs, jointly study and rectify difficult problems in the practice of fraud and insurance fraud, publish typical cases, and strengthen the use of cases to explain the law. Continue to improve mechanisms for data sharing, mutual transfer of leads, and joint investigation and joint handling with procuratorial organs and public security departments, simultaneously improve the efficiency of criminal crackdowns and administrative investigations, and promote the two-way connection between administrative law enforcement and criminal justice. Cooperate with the financial department to inspect the electronic bills of medical charges, and work together to implement the reward system for whistleblowing. Establish a clue transfer mechanism with the health department, and strengthen supervision from the front end of the medical norms involved. All departments should strengthen their connection and cooperation with discipline inspection and supervision departments, and actively hand over leads on suspected corruption-related issues. Relevant departments should integrate the centralized rectification of corruption in the pharmaceutical field with special rectification, integrated deployment, and integrated promotion.
(4) Persist in linking up and down, and make good use of clues for verification. At the national level, we will continue to play the role of a "baton", take clue verification as an important starting point for special rectification, strengthen assessment and incentives, supervision and supervision, and realize the linkage between the top and bottom and make efforts in the same direction. Local medical insurance departments should attach great importance to the suspicious data clues issued by the National Health Insurance Bureau, and carry out verification one by one to ensure that the clues are cleared to the bottom. Clues with a high risk level but slow verification progress should be included in the provincial cross-inspection, and the National Health Insurance Bureau will carry out spot checks and reviews as appropriate.
(5) Persist in treating both the symptoms and the root causes, and improve long-term mechanisms. Combine the rectification work with the improvement of the medical insurance fund supervision system and mechanism, find out and gradually solve the shortcomings and weak links of the medical insurance fund supervision system and mechanism, and improve the long-term mechanism for preventing fraud and insurance fraud. The National Health Insurance Administration will prepare to establish a "method database (experience database)" for fund supervision, summarize and refine the types of problems, modus operandi, inspection paths, big data supervision models, etc., and continue to improve the ability to identify and investigate fund regulatory risks. Explore the combination of special rectification work and credit management, further strengthen the main responsibility of self-management of designated medical institutions, promote medical institutions to continuously improve their internal management systems, consciously standardize medical service behaviors, rationally and effectively use medical insurance funds, and jointly maintain the safety of medical insurance funds.
5. Organization of work
(1) Start the deployment. The six departments jointly held the 2024 special rectification work conference on violations of laws and regulations in the medical insurance fund to mobilize and deploy the rectification work. (Completed in April 2024)
(2) Self-examination and self-correction. Supervise and urge designated medical institutions to carry out investigations on the list of benchmarking problems, comprehensively investigate all medical service behaviors and medical service expenses that have occurred since the implementation of the "Regulations on the Supervision and Use of Medical Security Funds", and implement reforms. (Completed May 2024)
(3) Centralized rectification. Focus on the key points of work, carry out joint rectification, and ensure that the special rectification work achieves practical results. (Completed in November 2024)
(4) Summary and reporting. All provincial-level medical insurance departments should promptly sort out the progress of the special rectification, analyze typical cases, strengthen the summary of experience and report the special rectification work. (Completed in December 2024)
Sixth, the work requirements
All levels of medical security, people's courts, procuratorial organs, public security, finance, and health departments should strengthen organization and leadership, strictly abide by discipline and rules, strictly regulate law enforcement, and faithfully perform their duties. It is necessary to strengthen publicity and guidance, and the National Health Insurance Bureau and various departments should coordinate the deployment of publicity and exposure. Medical insurance departments at all levels should establish a reporting mechanism for major matters, and report to the National Health Insurance Bureau in a timely manner for major cases investigated and dealt with and important cases to be exposed. It is necessary to strengthen public opinion monitoring and early warning, improve emergency response mechanisms, and avoid the formation of negative public opinion. It is necessary to establish an internal reporting mechanism, increase the intensity of internal reporting of typical cases for designated medical institutions, and strengthen warning education and deterrence.
编辑 | 张芷莹 责编 | 张秀丽
Integrated Sources | The official website of the National Medical Security Administration, the People's Daily health client
Produced by the Guangdong Health Online all-media team