Establish a full-field and full-process medical insurance fund safety prevention and control mechanism
Strictly combat fraud and insurance (policy interpretation)
In the future, fraud and fraud will be jointly supervised and severely cracked down, and those who are serious will be included in the list of joint disciplinary targets for dishonesty.
Recently, the State Council issued the "Guiding Opinions on Promoting the Reform of the Medical Security Fund Supervision System" (hereinafter referred to as "Opinions"), which clearly accelerated the reform of the medical insurance fund supervision system and established a full-field and full-process fund safety prevention and control mechanism. Severely crack down on fraud and fraud.
The system is not perfect, and violations of laws and regulations in the medical insurance field are prominent
Since the establishment of the basic medical security system, the coverage has been continuously expanded and the level of security has been gradually improved. It has played a positive role in safeguarding people's health rights, alleviating poverty due to illness, and promoting the reform of the medical and health system. However, due to factors such as imperfect regulatory system and imperfect incentive and restraint mechanism, the efficiency of medical insurance funds is not high, and the situation of fund supervision is more severe.
During medical insurance inspections, “hanging bed”, over-range management, minor illnesses, over-examination of medications, overcharges, decomposition charges, exchange charges and other fraudulent deception methods have emerged in an endless stream, and some institutions have committed fines and fines... The medical insurance system is not yet mature and finalized, and various violations of laws and regulations in the medical insurance field are prominent.
After the establishment of the National Medical Insurance Bureau in 2018, it continued to carry out special governance activities against fraud and deception of medical security funds, which played a deterrent role in attempts to violate the law and regulations. Statistics show that in 2019, medical insurance departments at all levels inspected 815,000 designated medical institutions, investigated and dealt with illegal and illegal medical institutions of 264,000, including 6,730 medical insurance agreements, 6,638 administrative penalties, and 357 judicial authorities transferred; There were 33,100 insured persons who violated the rules, 6,595 settlements were suspended, and 1,183 were transferred to the judicial organs; a total of 11.556 billion yuan was recovered throughout the year.
Clear powers and responsibilities, comprehensive and scientific supervision
According to the "Opinions", improve the fund supervision system, on the one hand, clarify the supervision authority and responsibility list, on the one hand, promote the reform of the supervision system, and at the same time, formulate regulations on the supervision and management of the use of medical security funds and supporting measures, strengthen the medical insurance fund supervision and rule of law, and standardize protection, Increase the punishment for fraudulent insurance fraud.
In terms of clarifying regulatory responsibilities, the "Opinions" proposes to establish a fund supervision working mechanism led by the medical security department and with the participation of relevant departments, to coordinate and coordinate major fund supervision major actions, and investigation and handling of major cases. Promote the reform of the regulatory system, and establish and improve various systems including supervision and inspection, intelligent monitoring, reporting and reward system, credit management system, comprehensive supervision, and social supervision.
"The issuance and implementation of the "Opinions" means that China's medical insurance fund supervision means will become more comprehensive and scientific, and a professional, intelligent, and rule-of-law supervision situation will gradually be formed in the future." Professor Shen of the School of Political and Public Affairs Management, Sun Yat-sen University Dawn said. my country's medical insurance supervision method is relatively simple, mainly based on agreement management, and agreement management is an afterthought management method with limited ability to restrict. "Opinions" comprehensively adopt a variety of supervision methods, such as daily inspection, credit management, information reporting, intelligent inspection of flight inspection, reporting rewards, people's congress supervision, social supervision and other means. "Diversified supervision methods adapt to the characteristics of long medical insurance fund management chain, multiple risk points, and strong concealment of fraud, which is conducive to the formation of comprehensive supervision. At the same time, it clarifies the supervision responsibilities of medical insurance, hospitals, and pharmaceutical departments, industry self-discipline, and individuals Obligations, etc., form the whole process supervision of the fund before and during the event."
Serious cases will be included in the list of dishonesty
In reality, many insured residents buy more medicines and have more tests in order to get enough medical insurance coverage and more reimbursement, but those who can see outpatients are hospitalized, which wastes medical insurance funds and medical resources. In this regard, the "Opinions" make it clear that the establishment of medical institutions and insured personnel medical insurance credit records, credit evaluation system and points management system. The designated medical institutions and individuals with serious fraud and fraud protection cases shall be included in the list of targets for joint disciplinary actions for dishonesty and joint disciplinary actions.
"The "Opinion" emphasizes the obligations of the insured, which is conducive to ensuring the safety of the fund." Shen Shuguang said. The supervision of the medical insurance fund is not only a matter of medical insurance, but also involves various aspects such as medical treatment, medicine, and insured persons. It needs all parties to cooperate and create an atmosphere of honesty and trustworthiness, clarify the rules for fund use, and emphasize the responsibilities and obligations of all parties.
Information technology will become a normalized supervision method. The "Opinions" mentioned that a comprehensive intelligent monitoring system should be established to accelerate the establishment of a centralized and unified intelligent monitoring system at the provincial and even the national level, so as to realize the transformation of fund supervision from manual bill review to full-scale, full-process and full-link intelligent monitoring of big data.
At present, the national unified medical insurance information platform is under construction, medical knowledge bases such as basic information standard libraries and clinical guidelines for medicines, medical treatment projects and medical service facilities are being improved, and some places have begun to use big data for supervision to achieve intelligent supervision. , Precision strike.
Zheng Gongcheng, a professor at Renmin University of China and chairman of the Chinese Society of Social Security, believes that strengthening the supervision of medical insurance funds and combating fraud and fraud will help improve the modernization of medical insurance governance, help build high-quality medical security systems, and benefit the people.
Our reporter Li Hongmei