In China's medical security system, the medical insurance fund undoubtedly plays a pivotal role, and how to manage and supervise scientifically and effectively often triggers in-depth thinking and heated discussions from all walks of life.
Recently, the National Health Insurance Administration, the Ministry of Finance, the National Health Commission and the State Administration of Traditional Chinese Medicine jointly issued the "2024 Medical Security Fund Unannounced Inspection Work Plan". This is not only a large-scale, university-based inventory of the medical field, but also a thorough investigation of the use of medical insurance funds. So, what is an unannounced inspection, how will it be implemented, and what will be the implications?
01
What is a Flight Check?
Unannounced inspections, as the name suggests, are like flying, quickly and suddenly, in the hope of being able to catch those violations that are not regulated. In fact, this policy has three major characteristics, which together build a rigorous and effective regulatory system for unannounced inspections.
First, the unannounced inspection is carried out in the form of "above and below, cross-checking", which is the responsibility of the higher-level medical insurance administrative agency, and is carried out in the form of vertical issuance and horizontal mutual inspection to ensure that the inspection process is more objective and fair.
Second, unannounced inspections have a high level of specialization. Not only the medical insurance department, but also the financial, health, traditional Chinese medicine and other departments jointly participated, and comprehensive supervision and inspection of medical insurance, medical treatment, medicine, finance, information and other fields can be carried out.
Third, unannounced inspection is a large-scale and centralized operation, which is jointly carried out by professional groups in policy, medical care, finance, and information, and these teams have their own tasks and cooperate with each other, which greatly improves work efficiency.
Since 2019, this method has been officially adopted by the National Health Insurance Administration as a review system, and after more than five years of efforts, more than 200 inspection team actions have been successfully launched, covering nearly 500 designated medical units across the country. This series of measures not only ensures the safety of medical insurance funds, but also brings positive results.
Undoubtedly, this is an abuse of public resources, a challenge to social justice, and an infringement on the interests of the majority of residents. Therefore, we must crack down on such behaviors to ensure social fairness and the effective use of medical insurance funds.
02
2024 Annual Unannounced Inspection Program
According to the newly released Work Plan, there will be changes to the regions and agencies for unannounced inspections in 2024.
First of all, the geographical coverage will fully cover all provinces, and the scope of random inspection cities will be further expanded.
Secondly, the inspection will be oriented to all kinds of institutions, and the provinces will conduct comprehensive inspections of public designated medical institutions, private designated medical institutions and designated retail pharmacies at the same time.
Finally, this year marks the first time that a "retrospective" has been implemented, i.e., a re-inspection of designated medical institutions that have previously undergone flight screening.
03
What are the main contents of the 2024 unannounced inspection?
According to the leaders of the National Healthcare Security Administration, the focus of the inspection includes the use and management of the medical insurance fund from January 1, 2022 to December 31, 2023, as well as the establishment and implementation of the internal control system, and if necessary, retrospective inspections of the previous year or the extension of the inspection scope to 2024.
For designated medical institutions, five key areas will be investigated and dealt with:
Focus on the illegal or irregular use of medical insurance funds in the fields of intensive care medicine, anesthesiology, lung cancer, etc., and focus on cracking down on fraudulent insurance fraud;
Focus on cardiology, orthopedics, blood purification technology, rehabilitation medicine, medical imaging, clinical laboratory and other fields that have been in-depth examination and self-correction in the past, and review whether self-examination and rectification have been carried out in accordance with the requirements;
For the designated medical institutions that are "return visits", the main inspection will be to check whether the problems found in the previous annual review still exist and whether they have been properly rectified;
Verify the online procurement of drugs and medical materials, especially whether public medical institutions comply with the regulations and purchase all required drugs and consumables through the provincial centralized procurement platform;
For patients who receive medical treatment across provinces and other places, review whether there is any illegal or irregular use of medical insurance funds.
For designated retail pharmacies, there are three main aspects of investigation and punishment:
Fraudulent drug purchases, including forging prescriptions or expense lists, empty or fraudulent medical insurance cards or medical insurance electronic vouchers;
Participate in the reselling of medical insurance drugs;
Settlement is made by substituting drugs or other products that are not reimbursed by the Medicare Fund for drugs that should be paid for by Medicare, and the "purchase, sale, inventory" records and financial books of Medicare drugs are falsified or modified.
Write at the end
The unannounced inspection in 2024 will be an important measure to maintain the fair distribution of medical resources and ensure the safe use of medical insurance funds. Let us hope that this unannounced inspection can provide a strong guarantee for the healthy development of medical security and better protect the rights and interests of the majority of insured personnel.