Got it back!, 80.5 billion yuan medical insurance fund inspection | Medical Insurance Bureau | Medical Insurance

At the briefing of the State Council Information Office on the 9th. The relevant person in charge of the National Medical Insurance Administration stated that since its establishment, the Administration has promoted full coverage of daily supervision for five consecutive years, and has jointly recovered 80.5 billion yuan of medical insurance funds with health and public security departments.

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Yan Qinghui, Deputy Director of the National Medical Insurance Administration: We have continued to carry out national medical insurance flight inspections, actively exposed typical cases, implemented a reporting and reward system, and initially established a high-pressure situation to combat fraud and insurance fraud. As of April 2023, the National Medical Insurance Administration has inspected 3.415 million designated medical institutions, processed 1.629 million cases, and recovered 80.5 billion yuan in medical insurance funds.

At present, the national unified medical insurance information platform has a daily settlement volume of about 18 million people, with a maximum daily settlement volume of about 34.76 million people, and regulates 950000 designated medical institutions and pharmacies. Since last year, the National Medical Insurance Administration has carried out key rectification measures in key areas such as orthopedics and cardiology, which have received strong feedback from the public.

Jiang Chengjia, Director of the Fund Supervision Department of the National Medical Insurance Administration: Firstly, focus on key areas such as orthopedics, blood purification, cardiovascular medicine, examination and testing, and rehabilitation therapy. The second is to focus on key drugs and consumables that rank high in medical settlement costs. The third is to focus on key behaviors such as false hospitalization and the resale of medical insurance drugs, and to specifically put forward work requirements for high-risk illegal and irregular behaviors after the implementation of policies for seeking medical treatment in other places and outpatient coordination.

The medication and follow-up examination after myopia surgery are directly related to the recovery effect of the surgery. Experts such as Zhang Fengju have stated that postoperative medication must strictly follow the doctor's advice and not blindly increase or decrease the dosage. The time for re examination is generally one day, one week, one month, three months, six months, and one year after the surgery, and routine re examination at the hospital is required at these time points. After surgery, if there is eye trauma, sharp decline in vision, eye pain, elevated intraocular pressure, etc., timely medical attention should also be sought.

State Council Information Office Holds Regular Policy Briefing for the State Council——

Weaving and Weaving Medical Insurance Fund Supervision Network

Recently, the General Office of the State Council issued the Implementation Opinions on Strengthening the Normalization Supervision of the Use of Medical Security Funds. On June 9th, the State Council Information Office held a routine briefing on State Council policies, inviting Yan Qinghui, Deputy Director of the National Medical Security Administration, as well as relevant officials from the Criminal Investigation Bureau of the Ministry of Public Security and the Medical Affairs Department of the National Health Commission, to interpret the Opinion and introduce the relevant implementation of the Opinion.

Taking multiple measures to solve the prominent and difficult problems faced by medical insurance supervision

The medical insurance fund is the "medical money" and "life-saving money" of the people. Yan Qinghui stated that since its establishment, the National Medical Insurance Administration has resolutely implemented the decisions and deployments of the Party Central Committee and the State Council, and has always regarded strengthening the supervision of medical insurance funds as its primary task. It has actively taken on and taken the initiative to promote full coverage of daily supervision for five consecutive years. It has also collaborated with health and public safety departments to carry out special campaigns to combat fraud and insurance fraud for five consecutive years. It has also carried out continuous national medical insurance flight inspections, actively exposed typical cases, implemented a reporting and reward system, and initially established a high-pressure situation to combat fraud and insurance fraud. As of April 2023, a total of 3.415 million designated medical institutions have been inspected, 1.629 million have been processed, and 80.5 billion yuan in medical insurance funds have been recovered.

"While achieving results, we are also soberly aware that the regulatory situation of medical insurance funds is still severe and complex." Yan Qinghui said that firstly, the "blatant" fraudulent behavior of designated medical institutions has been curbed, but the phenomenon of "running errands and leaking" is still quite common. The means of fraudulent insurance are becoming more covert, and fraud and medical corruption are intertwined, making regulatory difficulties continue to increase. Second, the promotion and implementation of reform measures such as off-site medical settlement, DRG/DIP payment reform, Internet plus medical insurance services, long-term care insurance pilot, and outpatient mutual assistance security have put forward new requirements for the establishment and improvement of fund supervision system and methods. Thirdly, the regulatory power of medical insurance is insufficient, the regulatory and enforcement system is not sound, and the regulatory responsibilities of all parties need to be further implemented.

"In response to the prominent and difficult problems faced in reality, the" Opinions "have put forward a series of specific measures, with the aim of strict supervision, striking a heavy fist, weaving a dense network of medical insurance fund supervision, and not giving opportunities for illegal and irregular behaviors such as fraud and insurance fraud." Yan Qinghui said that the "Opinions" mainly have the following characteristics:

One is to comprehensively consolidate the responsibilities of all parties and form a joint regulatory force. The regulatory responsibilities for each link of the use of medical insurance funds have been clarified, including administrative supervision responsibilities for medical insurance, audit and inspection responsibilities of medical insurance agencies, self-management responsibilities for the use of medical insurance funds by designated medical institutions, industry department supervisory responsibilities, and local government territorial supervision responsibilities. Clarified the boundaries of responsibilities for the use and supervision of medical insurance funds, ensuring that relevant departments fulfill their respective roles, fully leveraging the functional advantages of all parties, and promoting the formation of a comprehensive governance pattern of joint management.

The second is to adhere to systematic thinking and promote the construction of a comprehensive, multi-level, and three-dimensional fund regulatory system. Comprehensively summarize the practical experience of fund supervision over the past 5 years, clarify effective measures in reality, and use various regulatory methods such as flight inspections, special rectification, daily supervision, intelligent monitoring, and social supervision to effectively promote the supervision of medical insurance funds in a systematic manner.

The third is to focus on the construction of long-term mechanisms, promote the coordinated development and governance of medical insurance, medical care, and medicine. It is clear that we need to further establish and improve five mechanisms, including supervision and management mechanisms, collaborative supervision mechanisms, credit management mechanisms, cross regional supervision mechanisms for medical treatment in different regions, and mechanisms for handling major issues, to effectively solve various regulatory difficulties.

The regulatory workload of medical insurance funds is enormous, and effective regulatory experience has been accumulated

Yan Qinghui stated that the regulatory workload of the medical insurance fund is enormous: there are over 950000 designated medical institutions and pharmacies under medical insurance to be regulated; At present, the daily settlement volume of the national unified medical insurance information platform is about 18 million people, with the highest daily settlement volume of about 34.76 million people. 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.

"Last year, we summarized a set of effective inspection methods through flight inspections, and found out the situation of fraud and insurance fraud in high-value consumables in orthopedics, achieving a 'breakthrough on the spot'. This year, we made orthopedics one of the key contents of special rectification, and used these inspection methods to investigate and rectify designated medical institutions, promoting comprehensive standardization in the entire orthopedic field. Next, we will shift to normalized daily supervision, and introduce a nationwide unified list of supervision and inspection items, inspection guidelines, etc., to improve the professionalism and standardization level of daily supervision." Yan Qinghui said that through a combination of point, line, and surface, we will strive to achieve the inspection, thorough investigation, and standardization of one, so as to systematically promote the supervision of medical insurance funds. Deep and solid.

The second is to combine on-site and off-site monitoring to promote the normalization of intelligent monitoring. The supervision of medical insurance funds involves multiple objects and is difficult, and the regulatory power is relatively insufficient. On site inspections are difficult to cover in a timely and effective manner. Intelligent monitoring of medical insurance is one of the important measures to solve the pain points and difficulties of 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 comprehensively promoted the implementation of the reporting and 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 7.03 million yuan of reporting and reward funds have been redeemed nationwide.

Ensure the implementation and effectiveness of measures, and firmly uphold the safety bottom line of medical insurance funds

The Opinion emphasizes the formation of a joint regulatory force. Over the years, multiple departments have collaborated to achieve significant results in the special rectification of fraud and insurance fraud in the medical insurance field. Jiang Chengjia, Director of the Fund Supervision Department of the National Medical Security Administration, stated that this year's special rectification work has further strengthened departmental coordination, clarified and refined the responsibilities of medical insurance, public security organs, and health departments, and invited procuratorial organs and financial departments to join for the first time, forming a preliminary trend of comprehensive supervision of the five departments. Zheng Xiang, the head of the Criminal Investigation Bureau of the Ministry of Public Security, stated that the public security department will, in accordance with the requirements of strengthening the normalization of medical insurance supervision, vigorously crack down on illegal activities of defrauding medical insurance funds, strengthen the connection between pre -, during -, and post execution, and resolutely safeguard the security of the national medical insurance fund.

What are the new actions taken by the medical insurance department after the release of the Opinion?

Yan Qinghui stated that this year, the National Medical Insurance Administration will continue to strengthen the regulatory responsibilities of all parties, effectively strengthen the normalized supervision of the use of medical insurance funds, comprehensively use various regulatory measures such as flight inspections and special rectification, and strictly crack down on various illegal and irregular behaviors of fraud and insurance fraud with a zero tolerance attitude, firmly guarding the safety bottom line of medical insurance funds. At the same time, we will further implement the requirements of the Opinion from the following aspects.

One is to promote the implementation and refinement of intelligent monitoring. We will study and issue a notice on comprehensively promoting the intelligent review and monitoring of medical security funds. By the end of 2023, the intelligent supervision subsystem will cover all coordinated areas, conduct comprehensive intelligent review of all medical insurance settlement data, and preliminarily achieve a nationwide intelligent monitoring "one network". In combination with the pilot work of big data application, we will build a fund security technology defense line for full process supervision and management, including pre reminder, mid warning, and post monitoring.

The second is to further strengthen administration in accordance with the law. On the basis of summarizing the implementation of the Regulations on the Supervision and Administration of the Use of Medical Security Funds in the system, we will study the implementation rules of the regulations, enhance operability, promote more sound law enforcement basis for fund supervision, ensure lawful performance of duties, and maintain fund safety.

The third is to make good use of the comprehensive evaluation system for the supervision of medical insurance funds. We will closely focus on the key tasks determined in the Opinion, further improve the comprehensive evaluation system for fund supervision, tighten the main responsibilities of fund supervision at all levels of medical insurance departments, promote the construction of a regulatory pattern of linkage and joint management, and effectively play the role of the "baton" of comprehensive evaluation.

The fourth is to strengthen policy promotion. Make good use of both positive and negative examples, and severely punish the negative examples of illegal and irregular use of medical insurance funds. Timely public exposure should be made to play a warning and deterrent role; For advanced models of compliant use of medical insurance funds, we should increase positive publicity and play a positive incentive role.

"Strengthening the supervision of the medical service industry, regulating the behavior of medical services and the charging and billing behavior of medical institutions is an important responsibility of the health department." Li Dachuan, the head of the Medical Affairs Department of the National Health Commission, said that the National Health Commission will seriously implement the "Opinions", continuously improve the standardization level of medical services, strengthen internal control management of medical institutions, strengthen education and training, incentive guidance, and improve the monitoring and supervision management system, and effectively fulfill its responsibilities. At the same time, actively cooperate with the medical insurance department to do related work.