Direct Traffic to People's Livelihood | Guarding the People's "Medical Money" and "Life Saving Money" - Multiple Departments in China Strengthen the Normalization of the Use of Medical Insurance Funds and Supervise Medical Insurance | China

In order to further safeguard the "medical expenses" and "life-saving expenses" of the masses, the General Office of the State Council recently issued the "Implementation Opinions on Strengthening the Normalization Supervision of the Use of Medical Insurance Funds", which clearly states that it will accelerate the construction of a clear and rigorous regulatory system for the use of medical insurance funds with clear rights and responsibilities, strict and effective safety standards, and efficient rule of law.

How to strengthen the regular supervision of medical insurance funds? On the 9th, officials from relevant departments such as the National Medical Insurance Administration and the Ministry of Public Security gave an introduction at the State Council's regular policy briefing.

Weaving and Weaving Medical Insurance Fund Supervision Network

"As of April 2023, a total of 3.415 million designated medical institutions have been inspected, 1.629 million have been processed, and medical insurance funds of 80.5 billion yuan have been recovered." Yan Qinghui, Deputy Director of the National Medical Insurance Administration, introduced that a high-pressure situation to combat fraud and insurance fraud has been preliminarily established.

In response to the prominent and difficult issues faced, a series of measures have been proposed, with the aim of strict supervision, heavy lifting, and strengthening the supervision network of medical insurance funds, so as not to provide opportunities for illegal and irregular behaviors such as fraud and insurance fraud.

Yan Qinghui introduced that the opinion clarifies the regulatory responsibilities of each link in the use of medical insurance funds, including administrative supervision responsibilities of medical insurance, audit and inspection responsibilities of medical insurance agencies, and the main responsibility of self-management of medical insurance fund use by designated medical institutions, promoting the formation of a comprehensive governance pattern of joint management.

Among them, the review and inspection of medical insurance agencies is an important part of maintaining fund security. At present, the daily settlement volume of the national unified medical insurance information platform has reached 18 million people, with a maximum of 34.76 million people. The daily audit and settlement involving funds are all handled by the medical insurance agency.

Long Xuewen, the person in charge of the Medical Security Management Center of the National Medical Insurance Administration, introduced that the next step will be to make good use of the intelligent medical insurance review system, orderly achieve full coverage of annual inspections of designated medical institutions, and further implement the audit and inspection responsibilities of the handling institutions.

Promote the construction of a comprehensive, multi-level, and three-dimensional regulatory system for medical insurance funds

"The opinions clarify the effective measures that are effective in reality, and through various regulatory methods such as flight inspections, special rectification, daily supervision, intelligent monitoring, and social supervision, we can effectively combine regulatory measures." Yan Qinghui introduced.

Among them, flight inspection is a sharp sword for the supervision of medical insurance funds. Jiang Chengjia, Director of the Fund Supervision Department of the National Medical Insurance Administration, introduced that in recent years, the National Medical Insurance Administration, in conjunction with multiple departments, has continued to organize flight inspections, dispatching a total of 184 national flight inspection teams and inspecting 384 designated medical institutions.

In promoting the normalization of special rectification, Zheng Xiang, the head of the Criminal Investigation Bureau of the Ministry of Public Security, introduced that cracking down on illegal activities related to fraudulent medical insurance funds is an important part of the "100 day action" to crack down on public security in the summer of 2022. During this period, 1010 cases were solved and more than 450 million yuan in medical insurance funds were recovered.

Currently, it is difficult to detect illegal and irregular issues in the medical insurance field solely through the unilateral efforts of the medical insurance department. In order to strengthen the important role of social supervision in combating fraud and insurance fraud, in the second half of 2022, the National Medical Insurance Administration and the Ministry of Finance revised the relevant reward methods, increasing the maximum reward amount from 100000 yuan to 200000 yuan.

According to reports, since 2018, a total of approximately 1.7 billion yuan has been recovered nationwide based on verification of reported and complaint clues, and a total of approximately 7.03 million yuan in reward funds for reporting have been redeemed nationwide.

New technologies continuously empower the supervision of medical insurance funds

There are many regulatory points, long lines, and wide coverage for medical insurance funds, and it is necessary to weave a dense monitoring network, which requires the use of information technologies such as big data to empower the supervision of medical insurance funds.

"From individuals to groups, and then to doctors and patients colluding to defraud insurance, the forms of insurance fraud are covert and the methods are diverse." Jiang Chengjia gave an example of inducing hospitalization and false hospitalization. Criminals often collect medical certificates from insured individuals through returning cash gifts, providing free medical examinations, and other means to handle hospitalization. It is not uncommon for insured individuals to be "hospitalized".

Jiang Chengjia said that last year, with the help of establishing a "false hospitalization" model and big data analysis, more than 420000 designated medical institutions and nearly 3.8 billion massive data screening and analysis were completed in a week, and suspicious clues were discovered, effectively solving the problem of difficult and inefficient traditional manual verification.

In addition, the illegal sale of medical insurance drugs involves a wide range of personnel, multiple links, long chains, and obvious characteristics of cross regional crime, which is also a persistent problem of fraud and insurance fraud. Jiang Chengjia said that by developing a "medical insurance drug reselling" model, a batch of highly suspicious case clues have been screened. The next step will be to cooperate with public security organs to carry out precise crackdowns, with a focus on punishing "intermediaries" who resell medical insurance drugs.

In May 2023, the National Medical Insurance Administration announced the "Intelligent Audit and Monitoring Knowledge Base and Rule Base Framework System for Medical Security Funds". The knowledge base is the knowledge and basis required for intelligent audit and monitoring, and the rule base is the "red line" drawn based on the knowledge base for illegal and irregular behavior.

"At present, more and more designated hospitals are actively using intelligent monitoring to achieve self inspection and self correction, minimizing being held accountable or punished afterwards." Long Xuewen said that intelligent audit monitoring has become the "first line of defense" for medical institutions to use medical insurance funds in a safe and standardized manner.