Maintaining the safety of the use of medical insurance funds, reducing waste, and cracking down on insurance fraud are the key tasks of the National Medical Security Administration after its establishment. Under the continuous promotion of the medical insurance department, the special rectification has changed from fighting alone to coordinating and linkage, from passive response to active attack, from point rectification to surface governance, from case investigation to mechanism construction, a good situation of comprehensive management has been initially formed, the ecological environment used by medical insurance funds has been improved, and insurance fraud has been curbed to a certain extent.
■Lin Chunxia
Recently, the National Medical Security Administration and other six departments jointly issued the "2024 Special Rectification Work Plan for Violations of Laws and Regulations of the Medical Insurance Fund" (hereinafter referred to as the "Plan"), which will carry out the special rectification work of the medical insurance fund nationwide.
The special rectification will focus on the following aspects: First, focus on fraud and insurance fraud such as false diagnosis and treatment, false drug purchase, and reselling medical insurance drugs, and carry out severe crackdowns. The second is to focus on the 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. The third is to focus on key areas such as orthopedics, hemodialysis, cardiology, examination, testing, rehabilitation and physiotherapy, and comprehensively carry out self-examination and self-correction. In addition, defrauding maternity allowances, concealing work-related injuries to defraud medical insurance funds, and fraudulently using the insurance status of deceased persons to defraud insurance will also be the focus of the crackdown.
Six departments, including the National Medical Security Administration, jointly issued the "Plan" and focused on the above key points for rectification, which reflects the country's attention to issues in the field of people's livelihood. The medical insurance fund is the "medical money" and "life-saving money" of the people. In recent years, some criminals have used various means to defraud or overuse medical insurance funds driven by profits, especially the stubborn disease of reselling medical insurance drugs has not been eliminated, which involves a wide range of regions, large amounts of money involved, and a large number of participants, and gradually presents the characteristics of chain, systematization and specialization. In addition, the probability of false drug purchases such as false prescriptions in some outpatient clinics, empty medical insurance cards in pharmacies to withdraw medical insurance funds, and collusion of health care products for drugs in the medical insurance catalogue is also increasing. These acts of fraud and insurance fraud not only reduce the efficiency of the use of the medical insurance fund, affect the safety of the medical insurance fund, but also seriously damage the vital interests of the people, and must be severely cracked down.
In recent years, the state has attached great importance to the safety of medical insurance funds, and has continued to promote system governance by focusing on the key and difficult issues of fund supervision in response to the problems that the people have strongly resented. For example, in terms of special rectification, the unannounced inspection of the medical insurance fund has been carried out for 5 consecutive years, especially in 2023, focusing on the three major areas of internal control management of designated medical institutions, retail pharmacies, and medical insurance agencies to carry out unannounced inspections across the country, and comprehensively apply modern information technology means such as intelligent audit, intelligent monitoring, and big data supervision, so that the accuracy and effectiveness of supervision can be improved as a whole. In terms of policy measures, the promulgation of the "Interim Measures for the Administration of Unannounced Inspections of Medical Security Funds" and the "Implementation Opinions on Strengthening the Normalized Supervision of the Use of Medical Insurance Funds" provide an institutional basis for carrying out unannounced inspections in accordance with the law, and also indicate that the special rectification has entered the normalization.
Maintaining the safety of the use of medical insurance funds, reducing waste, and cracking down on insurance fraud are the key tasks of the National Medical Security Administration after its establishment. Under the continuous promotion of the medical insurance department, the special rectification has changed from fighting alone to coordinating and linkage, from passive response to active attack, from point rectification to surface governance, from case investigation to mechanism construction, a good situation of comprehensive management has been initially formed, the ecological environment used by medical insurance funds has been improved, and insurance fraud has been curbed to a certain extent.
First of all, in terms of departmental linkage. From the initial three departments to the current six departments for joint rectification, administrative law enforcement and criminal justice have been further effectively connected, and the joint force of departmental supervision has gradually taken shape.
Secondly, in terms of remediation priorities. From "fake patients", "fake illnesses" and "fake bills" to violations of laws and regulations hidden in real diagnosis and treatment, and also to key areas and key drugs in hospitals, its regulatory connotation continues to expand.
And finally, in terms of the way it is regulated. Since 2019, the National Medical Security Administration has carried out the demonstration construction of intelligent supervision in 32 provinces across the country, and by 2023, it will promote the use of the intelligent medical insurance supervision system by medical insurance information platforms across the country to promote intelligent review and monitoring. From the manual on-site review to the comprehensive application of modern information technology, the whole process of prevention and control of pre-reminder, in-process review and post-event supervision has been further realized, and it has played an effective role in cracking down on insurance fraud.
However, the problem of violations of laws and regulations in the field of medical insurance has the characteristics of history, extensiveness, and stubbornness, especially the concealment of insurance fraud methods is also becoming stronger, and the difficulty of dealing with it is also increasing, and the phenomenon of "running and dripping" still exists. In addition, with the deepening of medical insurance reform, fund supervision will also face new situations and new problems.
The joint rectification of the six departments on the issue of violations of laws and regulations in the medical insurance fund not only highlights the word "strict", but also forms a joint force of departments, and at the same time relies on digital empowerment to achieve "one network" supervision. Through comprehensive rectification, it aims to form a high-pressure situation of severe crackdown on various behaviors of insurance fraud and illegal use of medical insurance funds, ensure that the use of medical insurance funds is safer, more efficient and reasonable in the future, and effectively guard the people's "medical money" and "life-saving money".
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Chief Producer丨Wang Hui and Che Haigang
Producer丨Li Piguang, Wang Yu, Liu Weimin
Editor-in-Chief丨Mao Jinghui Editor丨Zou Duo