4 point practice suggests doing a good job of fine management within medical insurance fixed-point medical institutions.

On February 25,, the Central Committee of the Communist Party of China and the State Council issued the Opinions on Deepening the Reform of the Medical Security System, stating that safeguarding the security of the fund should always be the primary task, reform and improve the supervision system of the medical insurance fund, and strengthen the construction of the internal control mechanism of the public service institutions for medical securityComrade Hu Jinglin, Director General of the State Administration of Health Insurance, pointed out at the 2020 National Conference on Medical Security that on the basis of the special governance of combating fraud and insurance fraud in 2019, we should continue to carry out in-depth special governance work with self-examination and self-correction of fixed-point medical institutions as the coreThese requirements, for us to clarify the future period of time to combat fraud and fraud to maintain the security of the fund's goal and direction of effortsthe author has been engaged in clinical work in medical institutions for many years, served as the third-level hospital medical insurance section chief, but also in the health administration department in charge of primary health and drug administration and other work, well aware of the strengthening of fixed-point medical institutions internal medical insurance management, strict implementation of the importance of health insurance agreementsThis paper will combine the characteristics of the current fund supervision and the actual work, talk about strengthening the internal medical insurance management of fixed-point medical institutions internal control mechanism construction, for example, Xinyang City, the second-level and above fixed-point medical institutions a total of 57, including 53 public fixed-point medical institutions, private fixed-point medical institutions 4Through research, the current Xinyang City secondary and above fixed-point medical institutions have set up a special medical insurance management department or equipped with specialized (and) health care management personnel, fixed-point hospitals to the degree of attention to medical insurance gradually increased, but the management of medical insurance in different natures and different levels of hospital development imbalance and other issuesThrough research, it is found that there are the following problems in the internal medical insurance management of fixed-point medical institutions:the current fixed-point medical institutions medical insurance management in the construction of personnel, whether in terms of quantity and quality, or in the structure and staffing, there are unscientific, irregular, unprofessional and other issues, highlighted in the following aspects: First, the number of medical insurance managers is insufficientThrough research, it is found that the number of medical insurance management departments in our city's fixed-point hospitals varies from 3 to 10, but the proportion of full-time management personnel is very small, can not meet the needs of daily work; Most of the fixed-point hospital health care managers age structure is too large, and some are rehired from retired nursing staff, the aging of the staff is widespread; The investigation found that the city's fixed-point hospital medical insurance management personnel to this, specialized, professional background to nursing, finance-based, and generally low titles, medical insurance management, computer, clinical, legal and other professional background personnel shortage, it is difficult to adapt to the current hospital medical insurance management development needsthe current many fixed-point medical institutions medical insurance management departments have a clear functional positioning, the hospital attention is not enoughDue to the lack of independent legal person status in China's public hospitals, the management system of management still exists, the hospital in personnel, finance and other aspects of the lack of sufficient independence, the hospital management structure is not perfect, resulting in the medical insurance management department's function positioning is not clear enough, the relationship with other departments within the hospital is not straightened out, the relationship between hospital medical insurance management and medical service management is not clarified, supervision and management functions are not fully authorized and guaranteedIn addition, some fixed-point medical institutions pay insufficient attention to the medical insurance management department in the hospital, the orientation of their functions remains at the traditional level of thinking, and the hospital medical insurance management is not placed in the same important position as other work, resulting in the management of medical insurance being neglectedmany hospitals do not provide suitable performance appraisal standards, title promotion paths and career development paths for health care managers, resulting in many managers unwilling to engage in health insurance management, which is obviously not compatible with the new situation of universal health insurance reform and developmentby the end of 2019, the number of people insured by basic health insurance nationwide was 1.35 billion, and the coverage was stable at more than 95%Basic health insurance fund revenue of 2.33 trillion yuan, expenditure of 1.99 trillion yuan (data source: 2019 health care development statistics express) In 2018, the hospital expense fund within the scope of the employee health insurance policy paid 81.6%, the actual hospital expense fund paid 71.8%, the hospital expense fund within the scope of the residents' health insurance policy paid 65.6%, the actual hospital expense fund paid 56.1%, according to the medical institution grade, the hospital expense fund paid within the policy was: level 3 59.3%, second-level 69.1%, second-level and below 76.2% (data source: 2018 From the above data, it is not difficult to see the importance of health insurance to the designated medical institutions The internal medical insurance management of fixed-point medical institution refers to a set of institutions, mechanisms and management methods established within the fixed-point hospitals of medical insurance and corresponding to the medical insurance policy The internal medical insurance management department of fixed-point medical institution is the link and lubricant that connects the relationship between the fixed-point hospital, medical personnel and the medical insurance management organization, and it is the main force of the medical insurance management of the fixed-point medical institution, and it is also the nerve ending of the medical insurance supervision of the hospital The medical insurance administrative department should give full play to the advantages and enthusiasm of the internal medical insurance department of the fixed-point medical institution, stimulate its endogenous motivation, and strengthen the supervision and management of medical insurance with the full utilization of the hospital's own strength in order to realize the fine management of medical insurance within the fixed-point medical institutions, so that the management of medical insurance can be standardized and institutionalized, it is necessary to establish and improve the internal control mechanism of medical insurance in the hospital, according to the system management, according to the system The construction of organizational structure is the foundation and premise to strengthen the construction of medical insurance organization within the fixed-point medical institutions In 2013, the National Hospital Medical Insurance Service Code, formulated by the Professional Committee of hospital medical insurance management of the China Hospital Association, requires that the fixed-point medical institutions should establish and improve the medical insurance management system, set up a medical insurance management committee under the leadership of the hospital, and form a three-level medical insurance management network for hospitals, departments and departments; To Xinyang City as an example, through research, the city's more than 100 beds of fixed-point medical institutions, have set up a medical insurance department and other specialized medical insurance management departments, and by the hospital team members in charge of medical insurance work The position of the medical insurance administration department in the hospital departments has been gradually improved, and has become the first-level management department of medical institutions at the level of medical and political affairs, and the degree of management participation has been strengthened day by day Hospital health care managers are the propagandists and specific implementers of health insurance policies Therefore, the construction of medical insurance management personnel is related to the effectiveness and quality of the internal medical insurance management of fixed-point medical institutions First, the fixed-point medical institutions should strengthen the allocation of medical insurance management personnel in the hospital, optimize the internal personnel structure, introduce multi-disciplinary, multi-professional composite talents, improve the quality and level of medical insurance management personnel in the hospital; Incorporated into the higher education system and the national title promotion system, the formation of an institutionalized, standardized and scientific personnel long-term training system, and the third is to encourage fixed-point hospitals through the introduction of talents, the purchase of professional third-party medical insurance management services, strengthen personnel selection and training, and other ways to build a comprehensive quality, high professional level of the new hospital medical insurance management team, effectively make up for the current lack of supervision of medical insurance departments at all levels The medical insurance administrative department or the medical insurance administration shall, on a regular basis and irregularly, strengthen the management of the medical insurance managers of designated medical institutions in the overall area through medical insurance policy training and training on behalf of the conference The internal medical insurance management department of the fixed-point medical institution shall conduct regular and irregular medical insurance policy and management training for the whole hospital, not only for the director of the department, the head nurse, the medical insurance management personnel, the fee-paying personnel, the new medical personnel, etc., but also include the hospital leadership; At the same time, the training should be linked to the assessment to ensure the effectiveness of the training On the one hand, hospitals can promote the latest health insurance policies to insured personnel through official websites, WeChat public numbers, in-house electronic screens, posters, production of flyers and health insurance policy manuals, so that insured personnel are aware of policy changes and facilitate medical treatment On the other hand, hospitals can publicize their health insurance policies to hospital workers and inform them of medical insurance violations by regularly issuing internal periodicals such as the Management Monthly Report and the Medical Insurance Newsletter First, the fixed-point medical institutions should establish a medical insurance quality control assessment system, refine the scoring rules, monthly, quarterly and year-end respectively on the medical insurance policy, standard medical service behavior, charging standards, drug use, medical treatment, etc to assess, and the results of the assessment public Second, the formulation of reward and punishment measures, the establishment of reward and punishment system, the assessment results and departments, personal performance wages, annual assessment, labor employment, promotion of titles, cadres selection, and so on, and the implementation of the final elimination system, for more violations and the evaluation of the lower ranking of doctors, through the suspension of the right to prescribe medical insurance and other ways to punish Third, the health care department, especially the fixed-point medical institutions, should cooperate with the medical security administrative department to establish a medical insurance physician system, the designated medical institutions have the right to prescribe physicians into the medical insurance agreement physician management, refine the assessment indicators, and regularly summarize the results of the report, in order to restrain the behavior of medical insurance agreement physicians, urge them to strictly implement the relevant medical insurance provisions, fulfill the contents of the service agreement, and standardize medical service behavior The internal medical insurance management of fixed-point medical institutions is not only the responsibility of the medical insurance management department, but also the common responsibility of all departments of the whole hospital On the one hand, the fixed-point medical institutions should establish a multi-sector linkage system, set up a leading group, regularly or irregularly organize the hospital medical department, pharmacy department, nursing department, price office and other relevant departments jointly check the room, find the problem on-site office, on-site rectification, or by participating in the department morning meeting and other forms of centralized feedback to solve the problem in the room On the other hand, the medical insurance operators should hold regular meetings of medical insurance managers of fixed-point medical institutions to exchange problems with each other General Secretary Xi Jinping stressed that the health insurance fund should not be made a new "Tang monk meat", let the fraud, strengthen supervision Since the establishment of the National Health Insurance Administration, has always been to combat fraud and fraud to maintain the security of the fund as a top priority, hard to implement not relax This year, a very important part of the work to combat fraud and insurance is to fixed-point medical institutions self-examination and self-correction as the core of the special governance work The author believes that this work should become the norm On the one hand, the fixed-point medical institutions should establish the normalization mechanism of supervision and inspection, adhere to the problem orientation, establish a list of problems, focus on outstanding problems, dare to cut inward, self-check and correct, take one thing against three, find problems in a timely manner, and actively implement rectification On the other hand, the establishment of social supervision mechanism, open the way of social supervision, encourage the vast number of insured personnel, the media and other sectors of the community to participate in supervision, to achieve a virtuous circle of hospital development Fixed-point medical institutions at all levels should establish an analysis mechanism and early warning mechanism for the operation of medical insurance funds, and refine and strengthen the management of medical insurance funds We should strengthen the management of the core indicators of payment methods such as DRG or medical insurance total advance payment, hold regular medical insurance operation analysis meetings, conduct operational analysis of the annual medical insurance operation and core indicators of hospital departments, inform the existing problems, determine the direction of rectification, refine corrective measures and achieve effective management At the same time, according to the medical insurance payment standards and rules, the abnormal indicators and data for early warning, and communication with the heads of various departments to find out the reasons, find solutions, reduce the frequency of abnormal indicators, to ensure that the fund in a reasonable range of operation Since the establishment of the State Medical Insurance Bureau, we have vigorously promoted the construction of medical insurance informationization, and the construction of medical insurance information construction has been accelerated in an all-round pace In 2019, the State Health Insurance Administration selected 32 national demonstration points for intelligent monitoring of health insurance in the country, aiming to carry out the construction of intelligent monitoring of health insurance in the whole country in the form of "dot-and-point" Under this background, the fixed-point medical institutions in the process of all-round adaptation to the construction of medical insurance information, on the one hand, we must improve the level of information management of medical insurance, strengthen the network supervision of the medical insurance system, develop multi-functional operating platform and intelligent supervision system of medical insurance, improve the level of medical insurance management and fund use of fine On the other hand, we should cooperate with the "last kilometer" of the hospital's intelligent monitoring system, make the hospital HIS system and the medical insurance management system interconnected, and deepinto the medical insurance knowledge base and rule library into the hospital HIS system, so as to realize the three-dimensional supervision system of the whole process of medical insurance fixed-point medical institutions should strengthen the concept of "patient-centered", bearing in mind the purpose of serving the insured personnel, and constantly optimize the medical insurance, settlement process, to provide convenient medical insurance services for the insured personnel It is proposed to add "medical insurance consultation window", "green channel for poor personnel" and "referral window" in hospital consultation desks, toll offices and other places, so as to realize the one-stop service of "one-window" for inpatients, one-stop settlement, and continuously improve the level of service for the people January this year, the State Administration of Medical Insurance issued the Interim Measures for the Administration of Medical Security Fixed-Point (Draft for Comments), which will provide a legal basis for regulating the fixed-point management of medical security in medical institutions, improving the efficiency of the use of medical security funds, and optimizing the level of medical services for insured personnel In the country to continue to promote the fight against fraud and insurance in the background, fixed-point medical institutions through continuous strengthening of their own internal management, will be able to further standardize the medical behavior of fixed-point medical institutions, maintain fund security, for the vast number of insured personnel to create a good medical environment.