What does Shanghai rely on to safeguard the safety of medical insurance funds?, Over the past five years, nearly 600 million yuan of "life-saving money" has been recovered. Supervision | Inspection | Shanghai
This is an unusual meeting.
According to the inspection, we found that the hospital has problems such as excessive payment, duplicate charges, non-standard charges, and providing unnecessary medical services... Recently, in the conference room on the second floor of a designated medical institution in Shanghai, dozens of representatives from the medical insurance company and the hospital sat face to face at a long table. Listening to the medical insurance staff report the examination results, the hospital leader's expression was serious and tense.
Originally, the Supervision and Inspection Office of the Municipal Medical Insurance Bureau was holding a daily inspection feedback meeting here. Over the past five years, it has been through such daily inspections, as well as flight inspections, special inspections, and reporting investigations, that the Municipal Medical Insurance Bureau has recovered more than 550 million yuan from 11575 designated institutions that violated regulations, and more than 20 million yuan from 11696 individuals who violated regulations. A total of nearly 600 million yuan has been recovered from the medical insurance fund, effectively maintaining the safe and efficient operation of the fund.
Recently, the General Office of the State Council issued the Implementation Opinions on Strengthening the Normalization Supervision of the Use of Medical Insurance Funds, pointing out that strengthening the normalization supervision of the use of medical insurance funds is of great significance for ensuring the safe operation of medical insurance funds, improving fund utilization efficiency, regulating medical service behavior, and reducing the burden of medical treatment for the public. What new challenges are facing the supervision of medical insurance funds under the new situation? How will Shanghai strengthen regular supervision?
"Cat and Mouse Game" difficulty upgrade
The medical insurance fund is a life-saving money for the people. As of the end of 2022, the surplus of Shanghai Medical Insurance Fund has exceeded hundreds of billions of yuan over the years. "This is a considerable number, indicating that Shanghai's medical insurance has a relatively strong 'family background'. Industry insiders point out that the long-term stable accumulation of Shanghai's medical insurance fund provides strong protection for citizens to seek medical treatment.".
However, in the eyes of some people, "life-saving money" has become "Tang Monk's flesh". Gong Bo, the director of the Supervision and Inspection Institute of the Municipal Medical Insurance Bureau, told reporters that with the deepening of a series of medical insurance reforms, from seeking medical treatment in other places, long-term care insurance to outpatient assistance, the current use of medical insurance funds is becoming more extensive and diverse, and fraudulent insurance practices are becoming more covert and complex, bringing great pressure to regulatory work.
For example, in recent years, there have been numerous fraudulent behaviors in the field of elderly care insurance, with the most typical being "hanging empty orders", which means only checking in without providing services. Xu is a long-term care insurance caregiver in Shanghai. She heard about an example of "hanging empty orders" to collect long-term care insurance funds, so she colluded with her friend Zhou to apply for long-term care insurance for Zhou's disabled in laws. Afterwards, Xu regularly checked in at Zhou's home to complete the "on-site service", and then shared the nursing expenses with Zhou according to the agreed proportion. In fact, the two elderly people have never enjoyed nursing services. In addition, Xu and the family member of another insured person, Chen, cheated on insurance in the same way. In just over a year, three people cashed out over 48000 yuan of long-term care insurance funds.
Staff on-site interviews with insured individuals with abnormal medical expenses and visits
In addition, it is not uncommon for healthy elderly people to lie in bed, pretend to be sick, and defraud long-term care insurance funds when conducting disability level assessments. The chaos of false medical treatment, drug reselling under medical insurance, and cashing out from medical insurance have also been troubling the medical insurance department for a long time. However, such personal fraudulent insurance practices are not yet the main cause of fund losses. Gong Bo pointed out that "hospitals and doctors should also assume their due supervisory responsibilities.". Excessive diagnosis and treatment, excessive examination, excessive prescription of drugs, duplicate charges, and collusion of items... These common violations discovered during medical institution inspections have caused a significant loss of medical insurance funds and further damaged the personal and property rights and interests of patients.
However, in the current era of constantly emerging new therapies, technologies, and drugs, how to define violations has become a difficult problem. Gong Bo bluntly stated that whether a check should be done or not, sometimes the doctors, patients, and caregivers each have their own judgments, making it difficult to form a definitive conclusion. He said that in the most difficult to supervise mental health centers, patients may not even remember or know which tests and services they have received. Often, they can only distinguish by comparing the frequency of use reported by the hospital with the actual load of equipment, making verification work even more difficult.
Big data weaves a "web of heaven and earth"
"Relying solely on traditional supervision and inspection methods will only become increasingly inadequate."
Gong Bo's traditional methods mainly refer to manual inspection and verification. In September 2001, the predecessor of the Shanghai Medical Insurance Supervision and Inspection Institute, the Shanghai Medical Insurance Supervision and Inspection Institute, was born. This is the earliest medical insurance fund regulatory team established in the country. In recent years, it has continuously strengthened its regulatory power by attracting professionals in medical, legal, and financial fields. Currently, there are nearly 50 administrative law enforcement personnel. Together with the medical insurance bureaus and designated medical institutions in various districts, a three-level regulatory protection system has been established, which is jointly protected by municipal and district regulatory departments and designated institutions.
In order to enable this experienced team to play a greater role in the new situation, the construction of an intelligent medical insurance supervision system has been put on the agenda. Since 2015, the Municipal Medical Insurance Supervision and Inspection Institute has been exploring the application of big data technology to establish a warning indicator system for social medical institutions. In 2019, the Office of the National Medical Insurance Administration issued a notice on carrying out the "Two Pilots and One Demonstration" work of medical insurance fund supervision. In accordance with national standards and requirements, the Municipal Medical Insurance Bureau has innovatively constructed an intelligent supervision system, which comprehensively covers various types of medical insurance and regulatory objects. A comprehensive, comprehensive, and three-dimensional medical insurance intelligent supervision system has been built and put into use, covering the entire process in advance, during and after the event.
The reporter witnessed the operation process of this system during the supervision and inspection. The blue screen scrolls through an overview of the city's medical insurance funds, such as daily settlements and accumulated amounts for the current year, and presents real-time analysis results through visual models such as bar charts and heat maps. The system covers functions such as early warning and monitoring, monitoring case management, comprehensive queries, and rule screening. The most core early warning and monitoring functions are further divided into modules such as "multi card aggregation", "three fee warning", "person bed separation", "person card separation", "abnormal inspection", and "one face multiple cards".
Taking "multi card gathering" as an example, by clicking on a set of warning details, it can be seen that there are 4 insured persons involved here. They are of different genders and ages, and their workplaces and residences are also far apart. However, by chance, they appeared in the same hospital at the same time last year and prescribed the same medication, even with a single digit difference in settlement fees.
"This is likely not a coincidence." Gong Bo pointed out that the system's "multi card warning" function can automatically capture these originally inconspicuous doubts in massive medical insurance fund settlement information through technologies such as big data and artificial intelligence, and conduct intelligent analysis and rapid warning. In the above case, it is highly likely that the fraudster holds different people's medical insurance cards for medical treatment and then resells medical insurance drugs. In this regard, law enforcement personnel from the supervision and inspection office will follow the clues to the hospital for verification after seeing the warning on the system, and accurately crack down on fraudulent insurance fraud.
In addition, the municipal medical insurance department also focuses on exploring new applications of digital transformation scenarios for home care of long-term care insurance, "Internet plus" medical care, DRG/DIP payment and other new forms of medical insurance, further improving the intelligent supervision level of medical insurance, and accelerating the formation of a comprehensive digital supervision framework for medical insurance. For example, in the past, home care under long-term care insurance faced difficulties in recording the service process, quantifying the service content, and ensuring the service duration. In order to improve service quality and regulatory efficiency, the municipal medical insurance department introduced new technologies such as thermal imaging systems, voiceprint management systems, and facial recognition supervision systems, while obtaining the consent of the nursing staff and not infringing on privacy. The activity trajectory of nursing staff and the sound of making beds, washing hair, and feeding disabled elderly people can all be used as a basis for judgment, and non-standard behavior naturally decreases.
After confiscating drugs, the medical insurance fund supervision team cooperates with the public security department to conduct an inventory
The intensity and temperature of law enforcement
The Shanghai medical insurance intelligent supervision system forms a "sky net", and the medical insurance fund supervision team forms a "ground net". The fund safety "protection net" is tightly woven and strengthened, building a high-pressure regulatory situation.
"Only by 'managing' can we 'let go'," sighed the relevant person in charge of the Municipal Medical Insurance Bureau. In the view of industry insiders, this series of regulatory mechanisms for medical insurance funds not only effectively ensures the safety of medical insurance funds, but also brings many spillover effects. For example, in the past, in order to prevent fraudulent insurance practices, the medical insurance department restricted the variety, quantity, and amount of non prescription drugs purchased by citizens from designated retail pharmacies within the scope of basic medical insurance drugs. Citizens in need had to frequently go to pharmacies to purchase drugs. With the improvement of the fund supervision system, the Municipal Medical Insurance Bureau has recently optimized the management of designated retail pharmacies, lifted the above restrictions, and strengthened intelligent supervision to ensure the safety of the medical insurance fund while facilitating the purchase of drugs by the general public.
The work efficiency of medical insurance fund regulatory law enforcement personnel has also been significantly improved. A law enforcement officer told reporters that before teams enter hospitals for inspections, they often have already retrieved data from nearly a year or a half through intelligent supervision systems. With the help of big data, many violations have nowhere to hide. In the face of individual controversial behaviors, the supervision and inspection office will also invite external experts to make decisions, and "hospitals are generally convinced.".
In recent years, the high-pressure situation of medical insurance supervision has caused considerable pressure on designated medical institutions, especially the "point based" audit flight inspection, which adopts a mechanism of "no prior notice, above and below inspection, and cross inspection", effectively solving the problem of peer supervision in acquaintance society, and attracting high attention from the industry. But Gong Bo believes that the relationship between the medical insurance department and medical institutions has never been contradictory. "We need to promote the higher quality development of hospitals through medical insurance supervision and inspection.".
Balancing the intensity and temperature of law enforcement is therefore crucial. For example, charging for a high priced project is a common illegal and disorderly behavior, which involves charging for another project with a higher price even though the project is being done. "While we are investigating, we are reflecting on whether this is also related to the outdated charging standards, low pricing, or unreasonable price comparison relationship of medical service projects." Gong Bo said that for such situations, the supervision and inspection office will provide feedback to the Price Procurement Department of the Municipal Medical Insurance Bureau, which is responsible for price management of medical service projects, as an important reference factor for price dynamic management, fundamentally solving pain points and difficulties for hospitals.
Many times, hospitals make low-level mistakes because they are not familiar with the rules. Therefore, in Shanghai, in addition to daily inspections, flight inspections, and special inspections, law enforcement personnel also provide medical insurance policy training and case interpretation to hospitals, and inform hospitals of the inspection rules. Through publicity and training, medical personnel can enhance their understanding of medical insurance policies, strengthen their awareness of the rule of law, encourage self-examination and self correction, and regulate medical behavior. This type of preaching is quite popular in hospitals. At a feedback meeting, the director of a hospital in Shanghai expressed gratitude to medical insurance experts for their guidance and correction.
Supervise and inspect designated pharmacies
"Ultimately, maintaining fund security cannot rely solely on cracking down on fraudulent insurance measures." Industry insiders point out that previous issues such as inadequate regulatory systems, imperfect incentive and constraint mechanisms, inadequate payment systems, and lagging reforms have all brought risks to the management of medical insurance funds. In recent years, Shanghai has revised the "Shanghai Basic Medical Insurance Supervision and Administration Measures", taking the lead in issuing implementation opinions to implement the State Council's improvement of the medical insurance supervision system nationwide, and fully implementing the "Regulations on the Supervision and Administration of the Use of Medical Security Funds", continuously improving the supervision system. At the same time, we will revise and improve the management measures for designated medical institutions, improve the scoring management system for physicians and pharmacists, and the reporting and reward system, and promote the standardization, standardization, and legalization of administrative law enforcement in the supervision of medical insurance funds.
The relevant person in charge of the Municipal Medical Insurance Bureau stated that medical insurance departments at all levels in Shanghai will continue to strengthen daily supervision, improve long-term supervision mechanisms, further deepen departmental cooperation, promote social supervision, enrich supervision methods, increase exposure of typical cases, continuously improve the efficiency of medical insurance supervision, and promote the healthy and sustainable development of the medical insurance industry.
