Official construction of the whole area of health insurance fund security prevention and control mechanism to crack down on fraud and insurance.

Pharmaceutical Network July 14 - In the future, fraud and insurance fraud will be jointly monitored by many aspects, severe, serious people will be included in the list of joint disciplinary objects of breach of trustrecently, the State Office issued the Guidance on Promoting the Reform of the System of The Supervision System of the Medical Security Fund (hereinafter referred to as the Opinions), which clearly accelerates the reform of the system of supervision of the medical insurance fund, builds a comprehensive and all-process fund security prevention and control mechanism, and severely combats fraud and insurancesystem is not perfect, the phenomenon of illegality in the field of medical insurance highlights the establishment of the basic medical security system, the coverage has been expanding, the level of protection has been gradually raised, to safeguard the people's health rights and interests, alleviate poverty due to illness, and promote the reform of the medical and health systemhowever, the, due to the imperfect supervision system, the incentive and restraint mechanism is not perfect and other factors, the use efficiency of the medical insurance fund is not high, the fund supervision situation is more seriousmedical insurance inspection, "hanging bed", over-range operation, treatment of minor diseases, excessive examination of drug use, set of high fees, decomposition charges, serial exchange charges and other fraudulent means of insurance, some institutions committed penalties, penalties for reoffending ..At present, China's medical insurance system system has not yet finally matured, stereotyped, the medical insurance field exists in a variety of illegal and illegal phenomena prominentthe establishment of the National Health Insurance Administration in 2018, continued to carry out the special management activities to combat fraud and fraud of medical security funds, the phenomenon of attempts to violate the law has played a certain deterrent effectstatistics show that in 2019, medical insurance departments at all levels inspected a total of 815,000 designated medical institutions, investigated and punished 264,000 medical institutions for illegal and illegal violations, of which 6730 were released from medical insurance agreements, 6638 were administrative penalties and 357 were transferred to judicial organs;clear authority and responsibility, scientific supervision and scientific supervision in accordance with the Opinions, improve the fund supervision system, on the one hand, clear the list of regulatory powers and responsibilities, on the one hand, promote the reform of the regulatory system, on the other hand, formulate the regulations on the use of medical security funds supervision and management and its supporting measures, strengthen the supervision of medical insurance funds under the rule of law and standard protection, increase the punishment of fraud and insurance fraudin clarifying regulatory responsibilities, the Opinions propose to establish a mechanism for the supervision of funds led by the medical security departments and with the participation of relevant departments, and to coordinate and coordinate the supervision of major actions and investigation and prosecution of major cases by the Fundto promote the reform of the regulatory system, will establish and improve supervision and inspection, intelligent monitoring, reporting reward system, credit management system, comprehensive supervision, social supervision and other aspects of the systemthe issuance and implementation of the Opinions" means that China's medical insurance fund supervision means to be integrated and scientific, and will gradually form a professional, intelligent and rule-of-law regulatory situation in the future" said Shen Shuguang, a professor at Sun Yat-sen University's School of Political and Public Affairs ManagementChina's medical insurance supervision means a relatively single, mainly to agreement management, and agreement management is a kind of after-the-fact management means, limited constraintsopinions adopt a variety of regulatory methods, such as daily inspection, credit management, information reporting, intelligent monitoring of flight inspection, reporting reward, npc supervision, social supervision and other means " diversified supervision mode adapts to the characteristics of long chain of management of medical insurance fund, more risk points and strong concealment of fraud insurance, which is conducive to the formation of comprehensive supervision at the same time clear the medical insurance, hospitals, pharmaceutical departments of the regulatory responsibility, industry self-discipline, personal obligations, and so on, the formation of the fund before, the whole process of supervision " serious circumstances will be included in the list of the reality, many insured residents in order to use enough medical insurance quota, more reimbursement, buy more drugs, do more examination, can see out-patient but in-patient, this wastes the medical insurance fund, medical resources , the Opinions clearly establish the medical insurance credit records, credit evaluation system and points management system for medical institutions and insured persons to include the list of persons of joint disciplinary action for fraud and insurance fraud, and to implement joint disciplinary measures " Opinions emphasize the obligations of the insured and are conducive to ensuring the safety of the Fund ," Shen said the supervision of the medical insurance fund is not only a matter of medical insurance, but also involves medical care, medicine, insured persons and other aspects, need to cooperate with all parties to create an atmosphere of honesty and trustworthiness, clear the rules of the use of funds, emphasizing the responsibilities and obligations of all parties information technology will become the normal means of supervision the Opinions mentioned that the comprehensive establishment of intelligent monitoring system, accelerate the establishment of provincial and even national centralized and unified intelligent monitoring system, to achieve fund supervision from manual withdrawal audit to big data all-round, full-process, full-link intelligent monitoring transformation at present, the national unified health insurance information platform is being built, medicine, medical treatment projects and medical service facilities and other basic information standards library and clinical guidelines and other medical knowledge base is being improved, some places have begun to use big data for supervision, in order to achieve intelligent supervision, accurate combat Zheng Gongcheng, a professor at Chinese Min Min University and president of the China Society for Social Security, believes that strengthening the supervision of the medical insurance fund and combating fraud and insurance fraud will help to raise the level of modernization of medical insurance governance and help build a high-quality medical security system for the benefit of the people .