How to handle direct settlement of outpatient expenses across provinces? National Health Insurance Agency response

　　How to handle direct settlement of outpatient expenses across provinces?

The National Medical Insurance Administration gives a clear answer

　　Xinhua News Agency, Beijing, December 10 -

　　Xinhua News Agency reporter Peng Yunjia

　　Focusing on the medical settlement needs of 125 million inter-provincial floating populations, the direct settlement of medical treatments in different places across provinces is progressing in an orderly manner, which will further facilitate medical treatment and expense reimbursement for people working and living in different places across provinces.

　　How to handle direct settlement of outpatient expenses across provinces?

Which channels can be handled?

At the regular policy briefing held by the State Council on the 10th, the relevant person in charge of the National Medical Insurance Bureau introduced the relevant situation.

The inter-provincial direct settlement policy for outpatient and inpatient expenses is the same

　　"At present, the direct settlement service for outpatient expenses across provinces has covered 97.6% of the overall planning area and 120,000 designated medical institutions." According to Li Tao, deputy director of the National Medical Insurance Bureau, 91.7% of counties have more than one networked designated medical institutions. The cumulative settlement of outpatient services exceeded 10 million.

　　According to reports, outpatient expenses and hospitalization expenses are the same in the cross-provincial direct settlement policy: the list of medical places, the policy of insured places, and the management of medical places.

It can be explained as:

　　List of medical places-when direct settlement for medical treatment in different places across provinces, in principle, the payment scope and relevant regulations stipulated by the place of medical treatment shall be implemented, including the basic medical insurance drug catalog, diagnosis and treatment items and medical service facility standards, etc., are implemented in accordance with the policies of the place of medical treatment;

　　Insured area policy-the minimum payment standard, payment ratio, and maximum payment limit reimbursement policy of the medical insurance fund shall implement the policy of the insured area;

　　Management of the place of medical treatment-Participants must follow the service and management regulations of the place of medical treatment when seeking medical treatment across provinces, and the handling staff in the place of medical treatment shall provide the same handling services as the local insured person to people in other places.

　　To put it simply, when seeking medical treatment across provinces and other places, which medical insurance can be reimbursed shall be in accordance with the regulations of the place of medical treatment, but the reimbursement ratio and the maximum amount of reimbursement shall be in accordance with the regulations of the place of enrollment.

At the same time, the place of medical treatment should provide corresponding services for the insured person.

　　In terms of process, direct settlement of outpatient expenses across provinces requires filing.

Participants can go through the national medical insurance service platform App and the country's remote medical filing procedures, etc., without returning to the insured place.

　　After filing, patients can inquire about the regulations of the place of enrollment, and choose a designated medical institution in the inter-provincial and remote medical network at the place of medical treatment.

Then, in the admission procedures, discharge settlement, or settlement at the outpatient charging window, the insured person holds the original social security card or medical insurance electronic voucher for direct settlement.

"The medical insurance business office in your pocket"

　　"At present, there are more and more people seeking medical treatment in different places across provinces, and the coverage of real-time settlement is getting wider and wider. This requires more and more support for informatization." Wang Wenjun, Director of the Planning, Finance and Regulations Department of the National Medical Insurance Administration, introduced in recent years The work of informatization construction is constantly advancing, providing people with "medical insurance business offices in their pockets" and "medical insurance service points moved to their homes".

　　"Currently, the number of real-name users of the National Medical Insurance Service Platform App has reached 170 million." Wang Wenjun introduced that the National Medical Insurance Administration has developed the National Medical Insurance Service Platform App, as well as a small program for national medical records in other places, and has also built the National Medical Insurance Service Network Office. And it is interconnected with the national integrated government service platform to provide the masses with convenient and efficient cross-provincial and remote medical services.

　　In addition, the National Medical Insurance Bureau also relies on modules such as biometric identification and family accounts to provide medical insurance services such as face-swiping, relatives agency, and large-size version of the national medical insurance service platform App.

　　With the advent of the "Code Era", the National Medical Insurance Bureau has also given each insured person an electronic identity mark-medical insurance electronic voucher, which can handle all medical insurance services nationwide and omni-channel, effectively improving the efficiency of medical insurance business processing, and further Open up the "last mile" of medical insurance services.

　　Wang Wenjun said that at present, the number of omni-channel activation authorized users of medical insurance electronic certificates has exceeded 970 million, access to more than 340,000 designated medical institutions, and more than 370,000 designated retail pharmacies.

Strengthen the supervision of settlement funds for medical treatment in different places

　　Li Tao introduced that as the amount of direct settlement for medical treatment in different places across provinces is increasing, the National Medical Insurance Administration has further strengthened the supervision of funds for settlement of medical treatment in different places.

　　"The direct settlement of medical treatment across provinces and other places is to transform the traditional offline manual reimbursement into online information processing." Li Tao said, on the one hand, online expenses and settlement data can be stored through the network; another On the one hand, the realization of online traces of medical services and other data, process and result data can be conveniently and accurately retrieved, which lays a data foundation for the effective supervision of remote medical settlement funds.

　　In addition, the National Medical Insurance Bureau has further consolidated the supervision responsibilities of medical treatment places, that is, medical treatment agencies must not only manage local insured persons, but also conduct unified management of medical personnel in different places across provinces, and establish and establish medical treatment in designated medical institutions. Information records, medical behavior supervision, and medical expenses review must provide the same services and management as local insured persons.

　　"In recent years, we have made cross-provincial and remote medical treatment as one of the special work of medical insurance fund supervision." Li Tao said that specific measures include the coordinated verification of daily supervision through the insured area and the medical area, and regular analysis of cross-provincial and remote medical settlement data, and transfer Cases of suspected violations are checked and handled in relevant provinces, exploring the establishment of a cross-regional cooperative inspection work mechanism; relying on the medical security intelligent review system to conduct intelligent review and supervision of medical treatment and expenses; together with the Ministry of Public Security, focus on false patients, false medical conditions, and false medical conditions. Severe crackdowns on the "three fakes" of bills.