China News Service, July 9th, according to the Chinese government website, the General Office of the State Council recently issued the "Guiding Opinions on Promoting the Reform of the Medical Security Fund Supervision System" (hereinafter referred to as "Guiding Opinions"). The "Guidance Opinions" make it clear that the punishment for fraudulent insurance fraud will be increased, and the designated medical institutions and individuals with serious fraudulent insurance fraud will be included in the list of targets for joint disciplinary sanctions for joint fraud.
Data map: The nurse at the hospital's guiding desk fills in the information for the patient. Hu Jingshe
The "Guiding Opinions" pointed out that the medical security fund is the "medical care money" and "life-saving money" of the people. The Party Central Committee and the State Council attach great importance to the safety of the medical insurance fund. However, due to factors such as inadequate regulatory systems and imperfect incentive and restraint mechanisms, the use of medical insurance funds is inefficient, fraud and fraud are common, and the fund supervision situation is more severe.
The "Guiding Opinions" proposed that by 2025, the medical insurance fund supervision system and law enforcement system will be basically established, with the rule of law as the guarantee, credit management as the foundation, multi-form inspection, big data supervision as the basis, party committee leadership, government supervision, and social supervision , A comprehensive regulatory framework that combines industry self-discipline and personal trustworthiness to realize the rule of law, specialization, standardization, and normalization of medical insurance fund supervision, and constantly develop and improve in practice.
The "Guiding Opinions" require that a sound supervision and inspection system be established. Promote a "double random, one open" supervision mechanism, establish and improve a multi-form inspection system that combines daily inspections, special inspections, flight inspections, key inspections, expert inspections, etc., and clarify the inspection objects, inspection priorities and inspection content. Standardize the starting conditions, work requirements and work processes, clarify the rights and obligations of all parties, and ensure openness, fairness and justness. Establish a departmental linkage mechanism and carry out joint inspections to form a joint regulatory force. Actively introduce third-party forces such as information technology service institutions, accounting firms, and commercial insurance institutions to participate in the supervision of medical insurance funds, establish and improve government procurement service systems, implement pay-for-service performance, and improve the professionalism, precision, and effectiveness of supervision.
The "Guiding Opinions" proposes to establish and improve the reporting and reward system. The medical security and finance departments in the overall planning area and above should establish and continuously improve the system for reporting and rewarding violations of medical security laws, regulations, and breaches of contract, and reward whistleblowers in accordance with relevant regulations. Smooth the channels for complaints and reports, standardize the work processes and mechanisms such as acceptance, inspection, processing, and feedback, strengthen privacy protection, and effectively ensure the safety of the informants' information. Improve the reporting and reward standards, promptly honor the reward funds, and promote the active participation of the masses and all parties in the society in supervision.
The "Guiding Opinions" are clear and establish a credit management system. Establish an information reporting system for designated medical institutions. Establish medical institutions' credit records, credit evaluation systems, and point management systems for medical institutions and insured personnel. Innovate the comprehensive performance evaluation mechanism of designated medical institutions, and associate the credit evaluation results and comprehensive performance evaluation results with budget management, inspection and audit, and fixed-point agreement management. Strengthen and standardize the management of the list of trustworthy joint incentive targets and dishonesty joint punishment targets in the field of medical security, and implement joint trustworthy incentive and dishonest joint punishment in accordance with the law. Encourage industry associations to develop industry norms and self-regulation, formulate and implement self-regulation conventions, and promote industry norms and self-discipline.
The "Guidance Opinions" requires that the punishment for fraudulent insurance fraud be increased. Comprehensive use of judicial, administrative, agreement and other means to severely punish units and individuals that swindle and defraud insurance. Strictly implement the legislative interpretation of the Standing Committee of the National People's Congress on fraud and fraud, and transfer criminal cases to suspected criminal cases in accordance with law.
The medical security department increased administrative penalties in accordance with laws and regulations. Actively play the role of departmental joint punishment, and for the designated medical institutions that have been verified by the medical security department and the fraud and fraud are particularly serious, the health and drug regulatory authorities should suspend and rectify the business, revoke the qualification of the practitioner (operating), and restrict the practice, etc. Punish deterrence. The designated medical institutions and individuals with serious fraud and fraud protection circumstances shall be included in the list of targets for joint disciplinary actions for dishonesty and joint disciplinary actions.
The "Guiding Opinions" mentioned that the reform of the medical service system should be coordinated. Deepen the reform of the medical service supply side, accelerate the comprehensive reform of public hospitals, establish and improve the modern hospital management system, and standardize the diagnosis and treatment behavior. Focus on common diseases and health problems, standardize and promote appropriate medical technology. Continue to improve the market-led price formation mechanism for medicines and medical consumables, and improve the linkage mechanism between medical insurance payment and bidding procurement prices. Strengthen the supervision and inspection of the accounting information quality of the pharmaceutical industry, and carry out in-depth special treatment for the high prices of pharmaceuticals and high-value medical consumables.
The "Guiding Opinions" require that all provincial-level people's governments should establish an incentive and accountability mechanism to incorporate the work of combating fraud and fraud into the assessment of relevant work. It is necessary to strengthen accountability, proactively identify problems, investigate and deal with problems in accordance with laws and regulations, have zero tolerance for fraud and fraud, and openly expose typical cases. Effectively implement supervisory responsibilities, do a good job of connection, ensure that personnel are in place, responsibilities are in place, and measures are in place.