Pharmaceutical institutions fraudulent insurance, excessive abuse ... Become the key content of the special governance of the medical insurance bureau

On January 12, the State Administration of Health Insurance issued a notice on the implementation of special governance work to regulate the use of medical insurance funds by designated medical institutions for medical insurance (the "Notice").
"Notice" stressed that the medical security fund is the people's "life-saving money", we must always maintain the safety of the fund as a top priority.
Strengthen policy guidance and joint law enforcement by departments, crack down on fraud and insurance fraud with a "zero tolerance" attitude, standardize the service and charging behavior of designated medical institutions, improve the level of fine management of medical institutions, and ensure the safe, efficient and rational use of medical insurance funds.
the three-year violation of medical expenses "Notice" clear, comprehensive coverage.
is to cover all health insurance targeted medical institutions throughout the country, and the second is to cover all medical services and medical expenses covered by the Basic Medical Insurance Fund since 1 January 2018.
means that the cost of medical care covered by Medicare over the past three years will be self-checked and checked, and if non-compliant costs are found, the medical institutions will have to make a full correction and return them in full.
five categories of violations of "treatment of the disease" for different types of medical institutions and their diagnosis and treatment services behavior, highlighting the focus of governance, sub-category "treatment of the disease."
For public medical institutions to focus on the treatment of illegal charges, duplicate charges, over-medical insurance payment scope, no-fingered diagnosis and treatment, package-type examination, package-type treatment, high-set diseases, clinical experimental projects into the medical insurance reimbursement and other acts;
five governance contents (1) unreasonable charging.
Break down the fee-based medical treatment items into multiple project charges, double billing of the medical treatment items that already have a clear project connotation, exceed the prescribed fee standard charges, charge the self-created medical services not approved for inclusion in the medical insurance payment according to the medical insurance price items, double charges between the various package items, settlement of high-set diseases (disease groups) and so on.
(ii) the issue of serial exchange items (drugs).
will be out-of-catalog drugs, medical treatment projects, medical supplies string into the catalog charges, low-cost drugs, medical treatment projects, medical supplies to use high-priced charges.
(iii) irregular diagnosis and treatment.
the patient's inpatient treatment process is broken down into two or more hospitalizations; the admission of patients who obviously do not meet the hospitalization requirements is admitted to the hospital; and the use of drugs or medical supplies to be included in the medical insurance settlement within the limited scope of payment of the super-medical insurance catalogue.
(iv) Fictitious service issues.
, falsified or fictitious medical service settlement, forged patient information settlement, named hospitalization, forged or changed financial documents and purchase and sale deposit notes settlement, etc.
(v) Other violations of laws and regulations.
to carry out medical treatment services that do not conform to their own qualifications and incorporate them into the medical insurance settlement, to incorporate the drug clinical trial project irregularities into the medical insurance settlement, and to transfer the medical insurance network settlement to medical institutions that have not obtained fixed-point qualifications.
Governance timetable: self-examination and rectification before the end of October, spot checks before the end of November review, with the National Health Insurance Administration flight inspection through fixed-point medical institutions self-examination and rectification, medical insurance and health departments spot checks, flight inspection and other measures to strengthen the supervision of the health insurance fund, urge fixed-point medical institutions to improve the internal medical insurance management system, improve the level of medical insurance management and risk prevention and control capabilities, and effectively maintain the safety of the health insurance fund.
1, carry out self-examination and self-correction.
the end of October this year, the medical insurance departments and health and health departments of the co-ordination zones will organize and coordinate the comprehensive self-examination and rectification work of designated medical institutions in the district.
Each fixed-point medical institution shall check and rectify itself item by item against the contents of the governance, return the illegal and illegal income in full before the end of the self-examination and rectification, and deeply analyze the root causes of the illegal and illegal problems, clarify the rectification measures, the time limit for completion and the responsible person, and report the self-examination and rectification situation in writing to the local medical insurance department and the health and health department.
2, carry out spot checks and reviews.
The joint health and health departments of the medical insurance departments of the co-ordination areas shall, in accordance with the self-examination and rectification situation and the impact of the epidemic in the designated medical institutions in the co-ordination area, reasonably arrange the time to conduct spot checks and reviews, and in principle achieve full coverage of all fixed-point medical institutions in the co-ordination area.
provincial health insurance departments and health departments should strengthen overall coordination and supervision and inspection, and conduct spot checks on the self-examination and rectification of designated medical institutions in the region in due course.
provincial health insurance departments will report the special governance work to the National Health Insurance Administration and the National Health and Health Commission by the end of November.
3, carry out flight inspection.
health insurance bureau and the national health board will organize flight inspections covering all provinces of the country in due course.
health insurance departments and health departments throughout the country should actively cooperate with national flight inspections and provide relevant information as required.
provincial health insurance departments and health and health departments should, in accordance with the requirements of the relevant documents, carefully review the flight inspection team handed over the problem clues, in accordance with the law to do a good job of follow-up work.
the limited nature of china's health insurance funds is becoming increasingly "highlighted", the risk of health insurance bottoming out has increased significantly.
medical industry is about to usher in the "life-saving money" health insurance "strict supervision" of the normative era.
health insurance fund supervision involves a wide range, long chain of interests, multi-group game, illegal violations have formed a solid interest-related groups behind.
to regulate the use of medical insurance funds, improve the cost of illegal and illegal medical insurance, to regulate medical behavior and medical behavior can play an important legal deterrent.
Health insurance-oriented "value medical" to pay the bill, to "excessive medical and ineffective medical treatment" say no, drugs and supplies zero-plus, centralized procurement squeezes the space for inflated pricing, health insurance DRGDIP payment system reform and other measures, to ensure the safe, efficient and rational use of health insurance funds.