Reply from the medical insurance bureau: suggestions on the policy of the time limit for the advance payment of medical insurance funds by the hospital

On behalf of Wang Fengqiao, we have received your suggestions on the formulation of the time limit policy for the advance payment of medical insurance funds by the hospital, and we hereby reply as follows: 1 The problem that the medical insurance funds are not paid to the hospital in time and the medical insurance funds are not compensated in place The guiding opinions of the general office of the State Council on further deepening the reform of payment methods of basic medical insurance (GBF [2017] No 55) (hereinafter referred to as the "opinions") pointed out that "local medical insurance agencies with conditions in all regions can prepay part of medical insurance funds to medical institutions in accordance with the agreement, so as to relieve the pressure of fund operation" The basic medical insurance policy issued in 2016 According to the regulations on agreement management of medical institutions (hereinafter referred to as the regulations), the agencies should strengthen the budget management of medical insurance fund, improve the payment method and settlement method, timely review and allocate the medical expenses that should be paid by the medical insurance fund to the designated medical institutions according to the regulations In the process of agreement management, the settlement time limit of medical expenses should also be improved Strict requirements Generally speaking, most localities are able to allocate medical insurance expenses to designated medical institutions according to the time limit stipulated in the agreement, but some localities are in arrears Recently, the "Internet plus supervision" of the State Council has exposed similar problems Relevant places have carried out investigation and rectification work in the co-ordination area, and promptly allocated reasonable expenses to designated medical institutions The State Medical Insurance Bureau attaches great importance to the situation of arrears of fees It has interviewed relevant provinces, cities, districts and counties, carried out on-the-spot inspection on some regions, and carried out the rectification work on the problem of arrears of medical insurance fees of designated medical institutions nationwide Next, the medical insurance department will guide the local government to further improve the total amount control and agreement management, revise the agreement model, establish a long-term mechanism, standardize the time limit of medical insurance expenses allocation, and urge the local government to implement it Taking the construction of industry style as the starting point, we will promote the construction of industry style of medical insurance departments nationwide, optimize the business process of agencies, and further standardize the settlement and payment with medical institutions Combined with the construction of the national medical insurance information system under construction, optimize the medical insurance information system at the national level, so that the whole process of settlement and allocation of medical insurance expenses can be monitored and traced, so as to strengthen the supervision of medical insurance departments at all levels on the allocation of medical insurance expenses The financial department will actively cooperate with the medical insurance and other departments, on the basis of investigating the relevant situation, take measures to further improve the financing level of medical insurance, improve the financial accounting system of medical insurance fund, strengthen the equal consultation between medical insurance agencies and hospitals, and properly solve the problem of delinquency of medical insurance funds in hospitals It should be pointed out that in some cases, part of the funds advanced by the hospital is the medical insurance refusal expenses incurred by the medical institutions, and "medical receivables" refers to the medical expenses that should be paid by the relevant payers that have not been recovered by the hospital at the end of the period According to the medical insurance agreement, the non-compliance and unreasonable expenditure of medical insurance refusal is not within the scope of medical insurance payment, and the medical institutions shall bear it by themselves At the same time, in recent years, public hospitals have asked local financial departments to bear the cost of medical insurance refusal to make up for the hospital's "loss", which makes the hidden liabilities become the actual financial burden, increases the burden of medical insurance fund expenditure, and intensifies the financial risk of medical insurance fund underpaying 2、 As for the allocation of medical insurance funds to public hospitals, the medical insurance department has always adhered to the policy of treating medical institutions of different natures and categories equally in the management of designated medical institutions For the allocation of medical insurance funds, the guiding opinions of the general office of the State Council on further deepening the reform of the payment mode of basic medical insurance (GBF [2017] No 55) (hereinafter referred to as the "opinions") pointed out that "give full play to the third-party advantages of medical insurance, improve the incentive and restraint mechanism of medical insurance on medical behaviors and the control mechanism of medical expenses, and improve the self-management of medical institutions To promote the transformation of medical institutions from scale expansion to connotative development " Therefore, the payment of medical insurance fund is not based on the different ownership, but needs to establish an effective mechanism to promote medical institutions to strengthen the management of medical service behavior, actively reduce costs, control the excessive growth of medical expenses, and improve the quality of medical services The opinions on promoting the sustainable and standardized development of social run hospitals (gwyf [2019] No 42) jointly issued by the national health and Health Commission, the national development and Reform Commission, the National Health Insurance Bureau and other departments pointed out that "social run medical institutions are an important part of China's medical and health service system, which are to meet the medical and health service needs of different groups and provide more medical services for the whole society The important force of medical service supply ", and put forward" to increase the government's support for social medical service "," to improve the medical insurance support policy "and other opinions, requiring all regions and departments to put the development of social medical service in an important position 3、 As for the guidance on the reform and improvement of the comprehensive supervision system of the medical and health industry (GBF [2018] No 63) issued by the general office of the State Council on strengthening the supervision of private hospitals, it is clearly proposed to give full play to the guidance, supervision and restriction of all kinds of medical insurance on medical service behavior and strengthen the regulation and control of medical expenses We will comprehensively promote intelligent monitoring of medical insurance and actively explore effective ways to extend medical insurance supervision to medical service behaviors of medical personnel We will severely crack down on fraud and insurance fraud, and increase penalties in accordance with laws and regulations for fraud and insurance arbitrage, so as to ensure the safety of medical insurance funds Since the establishment of the National Health Insurance Bureau, it has attached great importance to the fund security work and taken a series of measures to severely investigate and deal with the fraud and insurance fraud of medical institutions, including private hospitals It has carried out the special action to combat fraud and insurance fraud and "looking back" work, unblocked the channels such as hotline, wechat, website, petition and so on, established the report and reward system of fraud and insurance, and improved the report and reward system We organized relevant departments, third-party organizations and media to carry out "flight inspection" to combat fraud and insurance, regularly exposed typical cases of fraud and insurance, carried out centralized publicity activities to "combat fraud and insurance and maintain fund safety", preliminarily constructed the situation of high-pressure deterrence to combat fraud and insurance, strengthened the wide attention and maintenance of medical insurance fund by the whole society A good atmosphere of safety According to the spirit of the 2018 national health industry style improvement video conference of the national health and Health Commission and the requirements of the notice on printing and distributing the special action plan for health industry style improvement (Guo Wei ban Yi Han [2018] No 18), combined with the actual situation of all provinces (regions and cities), we should focus on combating fraud and deception, "intraoperative price increase" and other damage to the industry image and people's groups As for the outstanding problems of public health rights and interests, the national health and Health Commission launched a three-month special action to rectify the style of health industry, which effectively cracked down on the illegal behaviors of medical institutions Next, the medical insurance department will strictly implement the deployment of the CPC Central Committee and the State Council, continue to carry out anti fraud and insurance actions, close loopholes, strengthen supervision, severely punish and severely deter, strengthen the supervision of medical insurance funds by guiding local governments to continue to carry out special treatment of fraud and insurance, realize the full coverage of designated medical institutions and expand the scale of flight inspection, and actively promote intelligent monitoring of medical insurance In the construction of demonstration sites, we will explore the mining and analysis of fraudulent insurance based on big data, improve the level of informatization, intelligence and efficiency of fund supervision; at the same time, we will introduce third-party forces such as information technology service institutions, accounting firms, commercial insurance institutions, establish a linkage mechanism among public security, health, market supervision, discipline inspection and supervision departments, innovate the fund supervision mode, and start the fund supervision We moved forward with the drafting of regulations on the supervision and administration of the use of medical insurance funds, carried out the pilot work of innovation in supervision methods and the pilot work of the construction of fund supervision credit system, and promoted the construction of a long-term mechanism for the supervision of medical insurance funds 4、 To increase commercial insurance, medical assistance and other different security systems to cover the whole people, and to introduce insurance companies to manage medical insurance fund mechanism (1) to improve the commercial health insurance security system The report of the 19th National Congress of the Communist Party of China made the decision and deployment of "comprehensively establishing the medical security system with Chinese characteristics" The reform of the medical security system in China has been pushed forward in depth, and a multi-level medical security system has been gradually formed, including basic medical insurance, supplementary medical insurance, serious illness insurance, medical assistance, commercial health insurance, philanthropic donation, to better meet the needs of multiple medical services In recent years, commercial health insurance has a strong momentum of development, playing a positive market mechanism advantage in the construction of multi-level medical insurance system, and playing an increasingly prominent role in meeting the growing demand of the people for health insurance In the future, with the gradual promotion of Health China strategy, the development of commercial health insurance will change from exploration period to sustained and rapid development period, and enter a new stage The premium income of commercial health insurance increased from 86.276 billion yuan in 2012 to 54.4813 billion yuan in 2018, with an average annual growth of 24.12% In 2018, the compensation expenditure was 174.43 billion yuan, an increase of 34.7% year on year The main product structure is major disease insurance and medical expense insurance, which better meets the health insurance demand of the insured people, and has accumulated more than 900 billion yuan of health insurance risk reserve Since 2001, with its advantages in actuarial technology, professional services and risk management, the insurance industry has taken the initiative to assume social responsibility, accept the entrustment of the government and the medical insurance department, and actively and steadily participate in the management of various medical insurance agencies In 2018, the insurance industry participated in all kinds of medical insurance project management, with entrusted management fund of 38.145 billion yuan, premium income of 28.5 billion yuan and service for 845 million people The cbcirc attaches great importance to giving play to the role of market mechanism to solve medical insurance problems, and actively encourages and guides insurance institutions to carry out all kinds of medical insurance handling services and vigorously develop commercial health insurance Next, cbcirc will continue to implement the health China strategic plan, encourage the insurance industry to accelerate the development of various forms of commercial health insurance, increase product supply, guide the insurance industry to deeply integrate the construction of multi-level medical security system, and contribute to the comprehensive establishment of medical security system with Chinese characteristics and the sustainable development of medical health industry In the process of promoting the goal of universal coverage of basic medical insurance, the medical insurance department will also improve and promote the development of commercial health insurance and play its role: first, encourage commercial insurance companies to develop marketable insurance products and services to meet the needs of people's multi-level, diversified and personalized medical insurance The second is to explore how to entrust commercial insurance institutions to undertake serious illness insurance by means of government purchasing services, so as to give full play to the advantages of commercial insurance institutions and improve the efficiency of system operation In the next step, in accordance with the requirements of the task of the central government's deep reform, in the top-level design of the medical security system with Chinese characteristics, we will simultaneously consider promoting the development of commercial insurance and strengthening the complementary connection with the basic medical security, implement the level of multiple medical needs security for the insured, and practically enhance the sense of access and satisfaction of the people （2） In recent years, to improve the medical assistance security system, the state has continued to improve the medical assistance system to effectively protect the basic medical rights and interests of the poor In terms of institutional arrangement, through providing subsidies to the poverty-stricken people who participate in the medical insurance, such as the special poor, the minimum living insurance and the poverty-stricken people who set up files and cards, they can help them obtain the basic medical insurance At the same time, through basic medical insurance, serious illness insurance and