Internet plus medical insurance payment work

November 2, the State Health Insurance Administration issued the "National Health Insurance Administration on actively promoting the "Internet plus" medical service payment guidance", pointing out that designated medical institutions to provide in line with the provisions of the "Internet plus" medical follow-up services, in accordance with the price of public hospitals general outpatient consultation items charge and pay. The cost of medicines occurred is paid in accordance with the standards and policies of payment stipulated in the offline medical insurance.Attached -Guidance of the State Administration of Medical Security on actively promoting the payment of medical insurance for "Internet plus" medical servicesHealth Insurance Issue No. 45Medical Security Bureau of provinces, autonomous regions, municipalities directly under the Central Government and Xinjiang Production and Construction Corps:for the implementation of the "State Council of the CPC Central Committee" Opinions on Deepening the Reform of the Medical Security System and the Opinions of the General Office of the State Council on Promoting the Development of "Internet plus Medical Health" (State Office Issued (2018) No. 26) spirit, strongly support the innovation of the "Internet Plus" medical service model, further meet the people's demand for convenient medical services, improve the level of medical insurance management services, improve the efficiency of the use of health insurance funds, and actively promote the "Internet Plus" The following comments are made on the payment of medical services.

, fully aware of the "Internet plus" medical services medical insurance payment of the importance ofAt the 14th meeting of the Central Committee for Comprehensive And Deepening Reform, General Secretary Xi Jinping said that the application of a new generation of information technology in the field of medicine and health should be given high priority, the management and service model of medicine and health should be reshaped, the allocation of resources should be optimized and the efficiency of services should be improved. To do a good job in the payment of medical insurance for "Internet plus" medical services is the outstanding embodiment of the people's psychological concept, and is an important driving force for deepening the reform of the medical and health system and deepening the reform of the medical security system. It is conducive to firmly establishing the new development concept, cultivating the new dynamics of the new industry, promoting the reform of the supply side of medical services and expanding the supply of high-quality medical services, promoting medical institutions and medical insurance organizations to improve the level of management, and providing convenient and efficient medical and medical insurance services for the insured. Health insurance departments at all levels should unify their ideological understanding, improve their political standing, and fully understand the importance and necessity of doing a good job in the payment of medical insurance for "Internet plus" medical services.

to do a good job of "Internet plus" medical service medical insurance payment should follow the following basic principles: First, optimize services, the people benefit the people. We will support the development of "Internet plus" medical services in line with the regulations, do a good job in connecting medical insurance payment policies, and give full play to the role of the Internet in improving the efficiency of the utilization of medical resources and guiding a reasonable order of medical treatment. Second, highlight the key points, and steadily expand. Priority should be given to ensuring the need for follow-up consultations such as outpatient chronic special diseases, and significantly improving the convenience of long-term drug patients seeking medical treatment. On the basis of the normative development of "Internet Plus" medical services and the improvement of medical insurance management and payment capacity, the scope of medical insurance payments has been steadily expanded. Third, online and offline consistent. We will implement a fair medical insurance payment policy for online and offline medical services, maintain a balanced level of treatment, and encourage fair competition among online and offline medical institutions. To adapt to the "Internet plus" medical service mode changes, and constantly improve and improve the management of medical insurance.Second, do a good job of "Internet plus" medical service medical insurance agreement management(i) clear "Internet plus" medical service agreement management scope. Under the framework of the relevant regulations of the health and chinese medicine administration departments at or above the provincial level, medical institutions that carry out "Internet Plus" medical services may voluntarily apply to the medical insurance agencies in the co-ordination areas where they are located for the signing of supplementary medical insurance agreements for "Internet Plus" medical services through the physical medical institutions on which they rely. If the physical medical institution is a non-fixed-point medical institution, it may apply for the supplementary agreement of "Internet plus" medical service at the same time as applying for the signing of the fixed-point agreement for medical insurance.(2) Medical institutions applying for the supplementary agreement on medical insurance for "Internet plus" medical services shall have the following basic conditions. First, with the national unified medical insurance information business code docking conditions, as well as drugs, medical supplies, medical treatment projects, medical services facilities, diseases and other basic information database. Second, with the conditions of data exchange with the medical insurance information system, combined with the construction of a unified national medical insurance information platform, to achieve mobile payment of medical insurance, can provide patients with electronic bills, electronic invoices or timely mailing of paper bills. Third, relying on medical insurance electronic vouchers for real-name certification, to ensure the true identity of the patient. Fourth, it is possible to completely retain the electronic medical records, electronic prescriptions, drug purchase records and other information in the course of the consultation and treatment of insured persons, so as to realize the whole process of diagnosis and treatment, prescription, distribution and so on can be traced. Fifth, to be able to verify patients for re-diagnosis patients, grasp the necessary medical information. Sixth, the hospital information system should be able to distinguish between the general offline medical service business and the "Internet plus" medical service business.

(iii) to do a good job in accordance with the provisions of fixed-point assessment and signing work. The regional medical insurance agencies shall, in accordance with the relevant provisions, evaluate and sign supplementary medical insurance agreements for medical institutions providing "Internet plus" medical services. The term of the supplementary agreement shall be consistent with the designated medical institution of the entity on which it depends. The co-ordinating regional medical insurance agencies shall publish to the public the list of designated medical institutions providing "Internet plus" medical services, the main service contents and the charging price.Third, improve the "Internet plus" medical service medical insurance payment policy(iv) according to the local medical insurance policy and the provision of "Internet plus" medical services of the fixed-point medical institutions to determine the scope of payment. The medical examination fees and drug fees that occur when the insured persons are re-diagnosed and prescribed by the designated medical institutions of the "Internet Plus" medical services in the co-ordination area may be paid in accordance with the provisions of the medical insurance in the co-ordination area. The expenses borne by the individual may be paid by the employee's personal account for medical insurance in accordance with the provisions. The cost of providing drug distribution services is not covered by health insurance payments. All regions can start from outpatient chronic special diseases, and gradually expand the scope of medical insurance for common diseases, chronic diseases "Internet plus" medical services.Combined with the pilot of direct settlement of outpatient expenses, the settlement process and treatment policy of off-site medical treatment as stipulated in the Notice of the Ministry of Finance of the State Administration of Medical Security on promoting the pilot work of direct settlement of outpatient expenses across provinces (Medical Insurance Issue No. 40 of 2020) explore the direct settlement of off-site medical treatment of "Internet plus" medical services.

(v) to implement the "Internet Plus" medical services price and payment policy. The price and payment policies shall be implemented in accordance with the relevant provisions of the Guidance of the State Administration of Health Care on Improving the Price and Payment Policy of "Internet Plus" Medical Services (Medical Insurance Issue No. 47 of 2019). For the new "Internet Plus" medical service price items declared by medical institutions, all localities should adhere to the principle of results-oriented, reflecting the law of resource consumption, reasonable convergence between online and offline, speed up the acceptance and examination, scientifically determine the name of the project, service content, units, charging methods, etc., to provide policy basis for cross-agency cooperation in the development of services and distribution of income. The designated medical institutions shall provide "Internet plus" medical follow-up services in accordance with the regulations, and shall charge and pay according to the price of the general outpatient examination items in public hospitals. The cost of medicines occurred is paid in accordance with the standards and policies of payment stipulated in the offline medical insurance. (vi) Support the transfer of prescriptions for "Internet plus" medical re-diagnosis. To explore the interconnection between the purchase prescription information of fixed-point medical institutions and the fixed-point retail pharmacy, the conditional co-ordination area can rely on the national unified medical insurance information platform, accelerate the application of the function module related to the transfer of purchased prescriptions, and facilitate the re-diagnosis and prescription flow of "Internet plus" medical services. Explore and carry out the coordination of inter-regional purchase prescription flow-related functional module mutual recognition, to achieve "information and prescription more running road, patients run less legs." Fourth, optimize the "Internet plus" medical service management services, medical insurance (7) to clarify the settlement object of medical insurance. The fees for medical service consultation and inspection of "Internet plus" in the co-ordination area in accordance with the provisions, as well as for medicines of the institutions providing the "Internet plus" medical services or their designated third-party institutions, shall be settled directly with the designated medical institutions of the entities by the medical insurance agencies of the co-ordination areas in accordance with the provisions of the portion to be paid by the medical insurance fund. The drug expenses adsigned by the "Internet Plus" medical follow-up prescriptions to fixed-point retail pharmacies in this co-ordination area shall be settled by the co-ordinating regional medical insurance agencies and fixed-point retail pharmacies in accordance with the provisions of the portion to be paid by the medical insurance fund. (8) Improve the management of the total budget. The total budget of the designated medical institutions providing "Internet plus" medical services shall be integrated into the unified management of the designated medical institutions of the entity. The calculation of the total budget should take into account the medical and pharmaceutical costs of "Internet Plus" medical services.

(9) to improve the level of medical insurance information management. We will accelerate the construction of a unified medical insurance information platform throughout the country, improve the construction of information modules such as the examination of the conformity of medical certificates, the examination of the conditions for re-diagnosis, the certification of electronic prescriptions, and the platform for the transfer of prescriptions, and accelerate the promotion and application of electronic medical insurance vouchers and medical insurance information business codes. (10) Strengthen the performance appraisal of designated medical institutions. The regional medical insurance agency or the third-party institution entrusted by it shall conduct performance appraisals on a regular basis for the medical institutions providing "Internet plus" medical services and the physical medical institutions on which they rely. Establish a system of assessment indicators based on the use of medical insurance funds, the quality of medical services, and the satisfaction of patients with medication. The results of the assessment are linked to the signing of fixed-point agreements, medical insurance payments, etc. (11) Improve the fixed-point exit mechanism. The regional medical insurance agencies shall improve the exit mechanism for the fixed-point medical institutions providing "Internet plus" medical services, and suspend or terminate the supplementary agreement in accordance with the provisions. Where an entity's fixed-point medical institution is suspended or dissolved from the agreement, the supplementary agreement providing "Internet plus" medical services shall be suspended or lifted at the same time, but if the medical institution providing the "Internet plus" medical service is suspended or dissolved from the agreement, the medical insurance agency shall decide whether to suspend or terminate the corresponding fixed-point agreement in accordance with the agreement of the entity's medical institution's fixed-point agreement.

, strengthen the "Internet plus" medical services regulatory measures (12) Strengthen the responsibility of the medical insurance department for cost audit. Medical insurance agencies should make comprehensive use of big data, the Internet and other technical means, the use of medical insurance intelligent audit monitoring system for the "Internet plus" medical service expenses settlement details, drugs, supplies, medical service items and outpatient medical records and other information for real-time supervision. Use audio, video and other forms to check the authenticity of "Internet plus" medical services to receive doctors. Comprehensively grasp the information of the insured person's visit and the relevant records of the medical institution's verification of the re-diagnosis. The non-compliant medical examination fees and drug fees shall be refused payment and shall be handled in accordance with the agreement. (13) We will crack down on fraud and insurance fraud in "Internet Plus" medical services. The medical insurance department should make full use of various means to strengthen the supervision and inspection of the designated medical institutions, focusing on the investigation and punishment of fraud and insurance fraud such as fictitious identity, false diagnosis and treatment, false opening of drugs and forged bills, and seriously investigate the relevant liability for violation of the law. In the event of fraud and insurance fraud, the insured person shall be suspended from using the "Internet Plus" medical service medical insurance payment or the direct settlement of the medical insurance in accordance with the provisions.

, the work requirements (14) Strengthen organizational leadership. All local medical insurance departments should attach great importance to the payment of medical insurance for "Internet plus" medical services, strengthen organizational leadership, do a good job in departmental coordination, implement responsibilities at all levels, ensure that the relevant deployment is implemented, and effectively serve medical institutions and insured persons. By the end of this year, the regional health insurance departments should, in accordance with the requirements of this opinion, formulate local "Internet plus" medical service medical insurance payment management methods, and improve the process of operation and the model agreement. (15) Do a good job of statistical monitoring. To coordinate the regional medical insurance departments to establish a statistical monitoring system for the payment of medical insurance for "Internet plus" medical services, do a good job of statistical monitoring, and strengthen the analysis of fund expenditures by reporting the number, type, amount and cost of medical services provided by "Internet plus" medical services included in the agreement management in accordance with the provisions. (16) Do a good job in policy training and publicity. We should strengthen training guidance, make medical personnel master the "Internet plus" medical service medical insurance payment provisions, and guide medical personnel to provide standardized medical services. Reasonable guidance to the people and medical institutions to expect, and actively respond to social concerns, for the "Internet plus" medical service development to create a good environment. The National Health on October 24, 2020