2023 National Medical Insurance Fund Flight Inspection Officially Launched
In order to thoroughly implement the decisions and deployments of the Central Committee of the Communist Party of China and the State Council, fully leverage the role of medical insurance fund supervision in anti-corruption in the medical field, crack down on various illegal and irregular behaviors in the medical insurance field, and resolutely safeguard the "medical treatment money" and "life-saving money" of the people, in accordance with the requirements of the "Notice of the National Medical Insurance Bureau, the Ministry of Finance, the National Health Commission, and the National Administration of Traditional Chinese Medicine on Carrying out the 2023 Medical Security Fund Flight Inspection Work", starting from August this year, the four departments will jointly organize medical security fund flight inspections covering 31 provinces and Xinjiang Production and Construction Corps in China.
The 2023 National Medical Insurance Fund flight inspection was officially launched today in Bijie City, Guizhou Province.
Flight inspections mainly focus on three aspects.
1、 Targeted medical institutions. This includes the internal control management and financial management of medical insurance, the execution of centralized and quantity based procurement of drugs, the application of nationally unified medical insurance information business codes, and the medical service and fee behaviors involved in the use of medical insurance funds. Focus on three areas: medical imaging examination, clinical testing, and rehabilitation.
2、 For retail pharmacies. This includes colluding drugs or other goods that are not paid by the medical insurance fund into medical insurance drugs, falsely brushing or stealing medical insurance certificates, forging or altering medical insurance drug inventory receipts and accounts, forging prescriptions or insured personnel expense lists, settling medical insurance expenses for non designated retail pharmacies, designated retail pharmacies or other institutions during the termination of medical insurance agreements, and other behaviors.
3、 Check the internal control management of medical insurance agencies. This includes daily review, payment, and verification of fees declared by designated medical institutions and insured individuals, determination of annual budget limits under DRG/DIP payment methods, and usage of intelligent review systems.
Since its establishment, the National Medical Insurance Administration has promoted full coverage of daily supervision for five consecutive years. It has collaborated with health and public security departments to carry out special rectification actions against fraud and insurance fraud for five consecutive years. It has continued to conduct national medical insurance flight inspections, actively exposed typical cases, implemented reporting and reward systems, and initially established a high-pressure situation to combat fraud and insurance fraud. As of June 2023, a total of 3.579 million designated medical institutions have been inspected, 1.703 million have been processed, and medical insurance funds of 83.5 billion yuan have been recovered.
The National Medical Insurance Administration introduced that the current situation of medical insurance fund supervision in China is still severe and complex. More than 950000 institutions across the country have been included in the regulation of medical insurance. Currently, the daily settlement volume of the unified medical insurance information platform in the country is about 18 million people, with the highest daily settlement volume of about 34.76 million people. Faced with so many regulatory targets and the use of medical insurance funds, the National Medical Insurance Administration has continuously explored and accumulated some effective regulatory experience.
One is to combine points, lines, and surfaces to promote the normalization of flight inspections, special rectification, and daily supervision. Among them, flight inspections focus on points, special rectification focuses on lines, and daily supervision focuses on areas. These three are organically combined and complement each other.
The second is to combine on-site and off-site monitoring to promote the normalization of intelligent monitoring. Intelligent monitoring of medical insurance is one of the important measures to solve regulatory pain points and difficulties. Through the promotion and application of intelligent monitoring, it is possible to achieve full process prevention and control of hospital front-end reminders, handling end in process reviews, and administrative end post supervision. In 2022, the total amount of medical insurance funds withheld and recovered nationwide through intelligent monitoring reached 3.85 billion yuan.
The third is to combine government regulation with social supervision to promote the normalization of social supervision. The National Medical Insurance Administration has always been committed to creating a fund supervision atmosphere in which the whole society participates, continuously improving the social supervision system, unblocking channels for reporting and complaints, and comprehensively promoting the implementation of the reporting reward system. Since 2018, the National Medical Insurance Administration alone has received more than 36000 reports and complaints. Based on the verification of the clues, a total of about 1.7 billion yuan has been recovered nationwide, and a total of about 7.19 million yuan has been redeemed as reward funds for reporting. At the same time, attention should be paid to the exposure of typical cases. As of June this year, a total of 267000 typical cases have been exposed nationwide, conveying a strong signal of cracking down on illegal activities such as fraud and insurance fraud with a zero tolerance attitude, and achieving a good warning and deterrent effect.
