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    Home > Medical News > Latest Medical News > Health insurance intelligent monitoring, third-party participation in regulatory new progress disclosure!

    Health insurance intelligent monitoring, third-party participation in regulatory new progress disclosure!

    • Last Update: 2020-10-01
    • Source: Internet
    • Author: User
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    On September 24th, the State Health Insurance Administration posted on its official website a letter on the reply to proposal No. 4218 (Social Management Class 359) of the Third Session of the 13th National Committee of the CPPCC, replying to a number of questions on fund supervision and disclosing the new progress in the introduction of third-party supervision and intelligent monitoring.
    the first results of local intelligent monitoring exploration, in fact, since the establishment of the National Health Insurance Administration, intelligent monitoring as a health care supervision of medical services has been highly valued.
    In particular, the Notice of the State Health Insurance Administration on doing a good job in the supervision of the Medical Security Fund in 2019 and the Notice of the Office of the State Health Insurance Administration on the Implementation of the "Two Pilots and One Demonstration" work on the supervision of the Health Insurance Fund not only clarify the direction of introducing third-party forces such as information technology service institutions, accounting firms and commercial insurance institutions, but also require all localities to improve the monitoring rules, refine the monitoring indicators and intelligent monitoring knowledge base according to the characteristics of fraudulent insurance fraud, and enhance the effectiveness of intelligent monitoring.
    At the same time, the State Health Insurance Administration has also selected some areas with high enthusiasm and a better information base to carry out intelligent monitoring demonstration point construction, explore the intelligent audit of medical expenses based on big data, enrich the monitoring dimension, and further improve the coverage and accuracy of intelligent monitoring.
    last year, 32 places with good basic conditions and high level of information technology were selected to explore the use of information platforms and information technology to initiate the work of intelligent monitoring demonstration points for health insurance.
    In its reply, the State Health Insurance Administration announced the progress of these demonstration point areas: among them, Tianjin, Zhangzhou and other places to improve the medical expertise library, medical insurance electronic medical records library and other databases;
    it is understood that the current medical insurance intelligent monitoring demonstration point exploration is also more complex monitoring.
    To the social health insurance insured up to 12.75 million people, involving the health insurance fund expenditure of about 14.5 billion yuan (2019 data), for example, the use of "face recognition and video surveillance" and other technical means, based on the large data disease grouping has been achieved, to achieve the city's disease grouping corresponding to the hospital remote check room, to ensure the accuracy of inpatients, timely detection of impostor hospitalization and other irregularities. according to
    , Guangzhou medical insurance intelligent monitoring system can also build a portrait model of disease treatment-related factors, form a standardized and reasonable treatment and cost of diseases, help predict the payment of disease funds, guide clinical optimization of diagnosis and treatment behavior, reduce fund risk. during the operation of
    , the management personnel of the medical insurance department may grab the registration information of the insured persons received by the fixed-point medical institutions, and initiate random or designated spot checks for inpatients - medical personnel for the initiated spot checks to check the task to identify whether there are any abnormalities;
    Compared with the construction of intelligent monitoring system, the introduction of third-party information technology service institutions, accounting firms, commercial insurance institutions and other third parties is expected to use their professional and technical support to establish and improve data screening, financial audit, medical records audit and other cooperation mechanisms.
    The mid-term evaluation of the pilot of regulatory innovation completed by the State Health Insurance Administration in July this year showed that 80% of the 26 pilot places such as Huzhou City, Gao'an City and Hebei Province, which carried out the "two pilots and one demonstration" of medical insurance fund supervision, had introduced commercial insurance companies to participate in fund supervision, and the pilot had generally achieved good results, and had explored experience for strengthening the supervision of medical insurance funds.
    According to the introduction, based on the Opinions of the State Council of the CPC Central Committee on Deepening the Reform of the Medical Security System, and the Guidance of the General Office of the State Council on Promoting the Reform of the Regulatory System of the Medical Security Fund, the regulatory system of the Medical Insurance Fund was clearly reformed and improved, and third-party supervision forces were actively introduced to establish and improve the government purchase service system.
    The State Health Insurance Administration actively explores the participation of commercial insurance institutions in fund supervision, and includes the cost of purchasing third-party services for fund supervision in the budget of the National Health Insurance Administration at this level, and introduces Chinese Life through tenders in 2019 and 2020. Commercial insurance companies such as People's Insurance Health, Taikang Pension, China United and Sunshine Life participated in the flight inspection work of the National Health Insurance Administration, of which 69 flight inspections were carried out by the 2019 bid agencies in 30 provinces across the country, and 2,232 million yuan was found to be in violation of the funds.
    In addition, in order to better evaluate the performance of third parties involved in fund supervision, this year the National Health Insurance Administration also set up a "purchase service performance evaluation and institutional research" topic, commissioned the Capital Medical University to the National Health Insurance Administration in 2019 to purchase services of commercial insurance institutions and other third-party institutions to carry out performance evaluation, evaluation dimensions including but not limited to personnel management, system construction, inspection quality, discipline and safety.
    time, commercial insurance companies to participate in the supervision of health insurance funds as one of the purchase of service tender items, explore the establishment of third-party institutions to participate in the supervision of the fund incentive constraints and survival mechanism.
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