China News Service, July 16 According to the website of the National Medical Insurance Administration, the National Medical Insurance Administration issued on the 16th "Opinions on Optimizing Convenient Services in the Field of Medical Insurance" (hereinafter referred to as "Opinions").
Among them, it is proposed to combat fraud and insurance fraud in the medical insurance field.
Encourage places where conditions permit to promote the use of face recognition technology, so that insured persons can "swipe their face" for medical treatment and hospitalization, and eliminate "fake patients"; double authentication of doctors "face-swiping + positioning" and eliminate "fake doctors"
Data map: People line up for registration in the outpatient hall of the hospital.
Photo by China News Agency reporter Yang Di
The "Opinions" are clear, adhere to the demand orientation, focus on the people's medical and medical insurance needs, make up for shortcomings, plug loopholes, strengths and weaknesses, and provide more intimate and heart-warming services.
Insist on convenience and efficiency, promote the deep integration of service innovation and information technology such as the Internet and big data, and promote flat, efficient, and intelligent handling of services, so that more data will run and the masses will run less errands.
Adhere to unified standards, strengthen management service rules and management service capacity building, promote the standardization and standardization of medical insurance services, and continuously improve service efficiency.
The "Opinions" propose that before the end of 2022, accelerate the promotion of the standardization, standardization and facilitation of medical insurance services, implement the reform of "at most once" for medical insurance services, and achieve "cross-provincial administration" of high-frequency medical insurance services to effectively improve the level of medical insurance services. .
On this basis, gradually establish a medical insurance management service system that is guided by humanity, guaranteed by the rule of law, based on standardization, and supported by information technology, and realizes the integration of national basic medical insurance, critical illness insurance, medical assistance and other medical insurance services.
The "Opinions" require that the standardization and standardization of medical insurance services should be promoted.
Promote the management of the list of medical insurance handling service items. By the end of 2021, realize the "six unifications" of the national medical insurance handling service item names, item codes, handling materials, handling time limits, handling links, and service standards, and adjust and update them in due course.
Medical insurance departments at all levels must resolutely cancel the processing links and materials beyond the requirements of laws, regulations and national policies in accordance with the "four best" requirements of the best service quality, the least required materials, the shortest time limit, and the simplest handling process.
Standardize and reduce the discretionary power of medical insurance payment, improve diversified payment methods, and actively promote payment by disease diagnosis-related grouping, total budget based on regional points, and payment by disease points.
Guarantee the basic medical needs of the insured persons and avoid surprise "control expenses" by medical institutions at the end of the year.
Promote medical insurance reimbursement integrated package services to ensure that the masses can handle medical insurance reimbursement as the main line, implement process reengineering, realize one-time notification, one-form application, and one-window processing, and effectively solve the problems of complicated medical insurance reimbursement application materials and complicated procedures.
Deepen the reform of "at most once" in medical insurance services.
Promote the “comprehensive teller system” at the service window of medical insurance handling, so as to realize one-window acceptance regardless of insurance types and matters at the front desk, and separate and joint operations at the back-end.
Encourage grassroots medical insurance management services to be stationed in the government service comprehensive hall, strengthen the business connection with human resources and social security, the People's Bank of China, taxation and other departments, and facilitate the "one-stop" joint operation of insurance registration and payment for the masses.
Explore the implementation of basic medical insurance, critical illness insurance, medical assistance, and commercial insurance settlement in a single settlement, at most once.
Promote "Internet + medical insurance services".
Optimize medical services. Insured people can choose to use social security cards (including electronic social security cards) and medical insurance electronic vouchers to buy medicines.
Relying on the national integrated government service platform, promote the online handling of medical insurance handling services, and realize "handheld operation" and "online operation".
Actively promote "Internet + medical services", follow the principle of online and offline fairness and medical insurance payment policies, improve protocol management and settlement processes based on service characteristics, actively explore information sharing, and realize integrated services of prescription circulation, online payment and settlement, and home delivery of medicines .
The medical insurance departments of all coordinating regions shall speed up the improvement of the management of the "Internet + medical service" medical insurance payment agreement in the region.
Unblock medical insurance consultation service channels, strengthen the construction of intelligent knowledge bases, and provide the masses with professional medical insurance hotline services with timely response, effective consultation and high resolution rate.
Actively explore the "video office" of medical insurance services.
Optimize the transfer and connection of medical insurance relationship and settlement of medical treatment in different places.
To meet the needs of population mobility and employment conversion, improve the policy for the transfer and continuation of the medical insurance relationship, actively promote the transfer and continuation of the basic medical insurance relationship across the coordination area, and realize the "inter-provincial transfer and continuation" of the basic medical insurance relationship.
Through the national integrated government service platform, the basic medical insurance relationship transfer and continuation service "online" and "nearest" are promoted, and the processing time limit does not exceed 20 working days.
Accelerate the direct settlement of basic medical insurance across provinces for medical treatment in different places, realize the national unified medical record for medical treatment in different places, and expand the scope of direct settlement for medical treatment in different places.
By the end of 2021, more than 60% of the counties in all provinces will have at least one inter-provincial networked medical institution for general outpatient expenses, and each coordinating area will basically achieve direct settlement of ordinary outpatient expenses across provinces; before the end of 2022, each county will have at least one designated medical institution Institutions can provide cross-provincial direct settlement services for medical expenses, including outpatient expenses.
Strengthen the data sharing between medical insurance and financial and taxation departments, establish and improve the national medical expense electronic bill library, and realize the docking with the medical insurance system and hospitals.
Gradually realize the online and offline integration of inpatient and outpatient expenses for medical settlement services in different places.
Promote medical insurance handling services nearby.
Vigorously promote the sinking of medical insurance handling services, give full play to the role of towns (streets) as regional centers serving urban and rural residents, and decentralize services such as insurance registration and payment, information inquiry and change, remote medical treatment filing, and sporadic (manual) reimbursement initial review ) First-level processing, and encourage the coordinating areas with conditions to be delegated to the village (community) level for processing.
Encourage the decentralization of matters closely related to the medical treatment process, such as the identification of chronic diseases in outpatient clinics and the enrollment of newborns, to designated medical institutions for handling.
Expand self-service functions, and set up self-service areas in designated designated medical institutions to facilitate people's inquiry and basic medical insurance handling services.
Optimize the agreement management of designated medical institutions.
Publicize the application conditions of designated medical institutions, implement list management of the required materials, and clarify the circumstances of non-acceptance, and no "glass doors" for social medical institutions, etc., are treated equally.
The coordinating regional agency shall promptly accept the designated applications from medical institutions and retail pharmacies and organize evaluations. If a consensus is reached through consultation, both parties voluntarily sign a service agreement.
Improve the medical insurance management service system.
Accelerate the establishment of a unified national medical insurance management service system to achieve full coverage of provinces, cities, counties, towns (sub-districts), and villages (communities).
Strengthen the service capacity building of grassroots medical insurance management offices, and promote the integration of medical insurance management services into county and rural public services.
Relying on township (street) service stations to improve the service system of grassroots medical insurance management.
Encourage the development of commercial health insurance, enrich insurance products, introduce third-party forces such as information technology service agencies, commercial insurance agencies, and social service agencies to participate in medical insurance management services, improve medical insurance actuarial standards, and establish performance evaluation and survival of the fittest adjustment mechanisms.
Strengthen the data support of medical insurance services.
In accordance with the goal of building a unified national medical insurance information platform, relying on a nationally unified technical system and structure, accelerate the implementation of medical insurance information platforms in various regions, and interconnect with the national integrated government service platform.
Fully implement the application of 15 information business coding standards, realize the "one code connection" of the national medical insurance system and various business links, and gradually realize the integration, in-depth mining and online application of medical insurance data.
Improve medical insurance integrated management, convenient services, intelligent supervision and scientific decision-making capabilities, and improve the modernization of medical insurance governance capabilities.
Strengthen the data management of insured participation in key groups such as employees in new employment forms, such as flexible employees, newborns, orphans, children who are actually unsupported, etc., to prevent "missing insurance" and "breaking insurance."
Using the national integrated government service platform as the data sharing hub, establish a data sharing switch between the medical insurance department and the education, public security, civil affairs, human resources and social security, health, veteran affairs, taxation, market supervision, rural revitalization, and disabled people’s federations. System, strengthen the comparison and dynamic maintenance of personnel information, and make the basic data of insurance participation.
Create a demonstration window for medical insurance handling services.
Strengthen the standardization of service windows for medical insurance management, improve infrastructure and equipment, unify service standards, and fully implement the one-time notification system, the first inquiry responsibility system, and the time-limited settlement system.
Implement the "good and bad reviews" system, strengthen the use of results, start pioneering and strive for excellence, strengthen the construction of service windows for medical insurance management, and carry out experiential evaluations and surveys on public satisfaction.
Accelerate the full coverage of service standardization windows for medical insurance agencies at and above counties and districts across the country to provide the masses with a better working environment and working experience.
Crack down on fraud and insurance fraud in the medical insurance field.
Strengthen the whole-process supervision of medical insurance funds, improve laws and regulations, and severely crack down on fraudulent insurance activities such as induction of hospitalization, false expense receipts, and excessive diagnosis and treatment in accordance with the law, and protect the "life-saving money" of the masses.
Relying on the unified national medical insurance information platform, accelerate the application of the medical insurance intelligent supervision subsystem, and fully connect with the medical institution information system.
In view of the characteristics of fraud and insurance fraud in the medical insurance field, improve the intelligent monitoring knowledge base and review rule database, strengthen the guidance and review of the clinical diagnosis and treatment behaviors of designated medical institutions, strengthen the supervision before and during the event, and use big data to screen for abnormal medical expenses after the event. Deal with it in a timely manner.
Encourage places where conditions permit to promote the use of face recognition technology, so that insured persons can "swipe their face" for medical treatment and hospitalization, and eliminate "fake patients"; doctors have "face-swiping + positioning" double authentication and eliminate "fake doctors".