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    Home > Medical News > Latest Medical News > State health insurance bureau: Regulations on the supervision of the use of medical security funds (Draft for comments)

    State health insurance bureau: Regulations on the supervision of the use of medical security funds (Draft for comments)

    • Last Update: 2019-04-12
    • Source: Internet
    • Author: User
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    In order to strengthen the legal construction of medical security, standardize the supervision and management of medical security funds, ensure the safety of funds, improve the efficiency of fund use, and safeguard the legitimate rights and interests of relevant subjects of medical security, our bureau has studied and drafted the regulations on the supervision of the use of medical security funds (Draft for comments), which are now open to the public for comments Before May 10, 2019, the public can make comments through the following ways and means 1 E-mail: zyf@nhsa.gov.cn; jjgs@nhsa.gov.cn2 Mailing address: no.2-9, Yuetan North Street, Xicheng District, Beijing, China Medical Security Bureau, post code: 100830, general rules of Chapter I of regulations of the State Medical Security Bureau on the use of medical security funds on April 11, 2018 (Draft for comments) Article 1 [objective basis] in order to strengthen the supervision and management of the medical security fund, ensure the safety of the fund, improve the use efficiency of the fund, and safeguard the legitimate rights and interests of the relevant subjects of the medical security, these Regulations are formulated in accordance with the relevant laws Article 2 [scope of application] These Regulations are applicable to the supervision of the use of medical security funds within the territory of the people's Republic of China The medical security fund referred to in these Regulations refers to special funds such as basic medical insurance for employees, basic medical insurance for residents, maternity insurance, medical assistance, etc The supervision and administration of serious illness insurance, long-term care insurance and other medical insurance funds shall be carried out in accordance with these regulations Article 3 [basic principles] the supervision of the use of medical security funds shall be in accordance with the law, objective and fair, with the same rights and responsibilities; in accordance with the government's leadership, social participation and self-discipline; in combination with prevention and investigation, encouragement and punishment Article 4 the State shall exercise strict supervision over the use of medical security funds The people's governments of provinces, autonomous regions and municipalities directly under the central government shall, in accordance with these regulations, establish and improve the supervision system of medical security funds to ensure the safe and effective use of medical security funds The people's governments at or above the county level should strengthen the construction of supervision capacity of medical security funds, encourage and support all sectors of society to participate in the supervision of medical security funds Article 5 [Responsibilities of departments] the administrative department of medical security under the State Council shall be in charge of the supervision of medical security funds throughout the country, and other relevant departments under the State Council shall be responsible for the supervision of medical security funds within the scope of their respective responsibilities The administrative department of medical security of the people's government at or above the county level shall be responsible for the supervision of the medical security fund in its own administrative area, and other relevant departments of the people's government at or above the county level shall be responsible for the supervision of the medical security fund within the scope of their respective duties Article 6 [administrative department of medical security] the administrative department of medical security shall, in accordance with the law, supervise the medical service behaviors and medical service fees using the medical security fund, and investigate and deal with the illegal behaviors in the field of medical security The administrative department of medical security shall supervise the medical security supervision and law enforcement agencies, agencies, designated medical institutions, designated retail pharmacies (hereinafter referred to as designated medical institutions), agreement management physicians and pharmacists, insured personnel and medical aid objects to observe the laws and regulations of medical security Article 7 [supervision and law enforcement agencies] the medical security supervision and law enforcement agencies are entrusted by the administrative department of medical security to carry out the supervision and inspection of medical security and other administrative law enforcement work Article 8 [implementation of supervision agreement] the administrative department of medical security of the people's government at or above the county level shall supervise the signing and performance of the designated service agreement between the agency and the designated medical institution, and supervise the inspection and examination of the designated medical institution by the agency Article 9 [joint supervision] the administrative department of medical security of the people's government at or above the county level shall, according to the needs of the work, conduct joint inspection with relevant departments Article 10 [Third Party Supervision] the administrative department of medical security of the people's government at or above the county level may employ qualified third-party institutions to investigate the medical service behaviors of designated medical institutions using medical security funds, and audit the establishment and implementation of internal control system, payment of medical security benefits, signing of service agreements and other management and use of medical security funds by the agencies Or assist in the investigation Article 11 [inspection methods] the administrative department of medical security of the people's government at or above the county level shall supervise and inspect the agencies, designated medical and pharmaceutical institutions, insured personnel and medical assistance objects by means of daily supervision and special supervision, on-site supervision and inspection and off-site supervision and inspection, internal supervision and external supervision Article 12 [credit management] the administrative department of medical security under the State Council shall be responsible for the credit management in the field of national medical security and incorporate it into the social credit system The specific measures shall be formulated by the administrative department of medical security under the State Council Article 13 the administrative department of medical security under the State Council shall establish an information reporting system for designated medical institutions The administrative department of medical security of the people's government at or above the county level shall strengthen the inspection, spot check, analysis and application of the report information of designated medical institutions, and handle the problems found according to law Article 14 [flight inspection] the administrative department of medical security under the State Council shall establish a working mechanism for flight inspection The administrative department of medical security under the State Council shall be responsible for organizing and implementing nationwide flight inspection The provincial administrative department of medical security shall be responsible for organizing and implementing the flight inspection within its own administrative area Article 15 [intelligent monitoring] the administrative department of medical security of the people's government at or above the county level shall innovate the supervision methods, popularize the use of information technology means in the field of fund supervision, build the intelligent monitoring information system of medical security of the region, realize the full coverage of supervision and improve the effectiveness of supervision Article 16 [reward for reporting] the administrative department of medical security of the people's government at or above the county level shall establish a reward system for reporting fraud, standardize the investigation and handling of clues, and protect the legitimate rights and interests of whistleblowers according to law If it is verified to be true, the informer shall be rewarded according to relevant regulations Any unit or individual shall have the right to report and complain against any illegal act against the medical security fund Article 17 [supervision by the people's Congress] the supervision of the use of medical security funds by the people's governments at or above the county level shall be subject to the supervision of the people's congresses and their standing committees at the corresponding levels Article 18 [social supervision] the administrative department of medical security of the people ' Article 19 the medical security agencies shall abide by the following provisions: (1) establish and improve the internal control system of medical security funds in accordance with the relevant national fund budget and final accounts system and financial accounting system; (2) establish a collective negotiation and negotiation mechanism with designated medical institutions, and sign and perform service agreements in accordance with the law; (3) Check and verify the service behavior of designated medical institutions in accordance with the agreement; (4) handle the breach of contract behavior of designated medical institutions in accordance with the agreement, if administrative punishment is needed, transfer it to the administrative department of medical security at the same level; (5) not organize or participate in the falsification of certification materials to defraud, occupy or misappropriate the medical security fund; (6) Other obligations stipulated by laws and regulations and service agreement Article 20 [designated medical institutions] the designated medical institutions and their staff shall comply with the following provisions in providing medical security services: (1) strictly implement the provisions of medical security management and the agreement; (2) report the information required for supervision to the administrative department of medical security as required, and be responsible for the authenticity and integrity of the information; (3) Issue detailed medical expense documents and relevant materials to the insured and the medical aid objects; (4) check the effective medical security certificates of the insured and the medical aid objects to ensure the consistency between the human and the evidence; (5) stop the suspected fraud and insurance fraud, and report to the administrative department of medical security if the circumstances are serious; (6) It is not allowed to forge and alter prescriptions, medical records, treatment and inspection records, medicine and medical equipment in and out records, financial accounts and other materials to defraud the medical security fund; (7) other provisions on the management of medical security Article 21 [doctors and pharmacists under Agreement Management] doctors (including assistant doctors who can practice independently) in designated medical institutions and pharmacists and pharmacists in designated retail pharmacies who are included in the agreement management shall provide medical security medical services in accordance with the following provisions: (1) providing medical services in accordance with the provisions of medical security management and the agreement; (2) Provisions on the management of doctors and pharmacists in the medical security agreement; (3) not to forge and alter prescriptions, medical records, treatment and inspection records, medicine and medical equipment in and out records, financial accounts and other materials to defraud the medical security fund; (4) other provisions on the management of medical security Article 22 [personal obligations] the insured and the medical aid objects who use the medical security fund to seek medical treatment and purchase drugs shall abide by the following provisions: (1) to seek medical treatment and purchase drugs with their own valid medical security certificates and actively present them for inspection, and shall not lease (lend) their own valid medical security certificates to others; (2) It is not allowed to forge and alter the certification materials to defraud the medical security fund; and (3) other provisions on the management of medical security Article 23 No unit or individual may organize, abet, induce, coerce or help others to defraud medical security funds Article 24 [active cooperation] when the inspected object is subject to the supervision and inspection of the administrative department of medical security, it shall actively cooperate, provide the required data as required, and shall not refuse the inspection, make false report, make false report or conceal the report Article 25 [confidentiality provisions] the administrative department of medical security and other relevant administrative departments, medical security agencies and their staff shall not use the information or information obtained for any purpose other than fund management, and shall not disclose the personal privacy and business secrets of the parties Chapter V Legal Liability Article 26 [handling of breach of contract] for designated medical institutions that defraud medical security fund expenditures through unreasonable medical behaviors, fictitious medical services or other ways, the agency shall, according to the signed service agreement, give warning interviews, rectification within a time limit, suspend appropriation, suspend departmental settlement, suspend the qualification of medical (pharmaceutical) service, suspend the online settlement of medical institutions, and suspend the temporary settlement Stop the designated agreement of medical institutions until the agreement is terminated If the agency fails to perform its obligations in accordance with the service agreement, the designated medical institution may make a complaint and report to the administrative department of medical security If it is verified to be true, the administrative department of medical security shall order it to make corrections within a time limit, and give corresponding punishment to the person in charge and the person in charge of the agency according to the seriousness of the case Article 27 [punishment for violation of laws and regulations] according to the violation of laws and regulations, the administrative department of medical security has the right to make the following punishments: warning, confiscating the illegal income and imposing a fine of more than two times but less than five times the illegal amount, ordering the agency to suspend or terminate the qualification of medical (pharmaceutical) service, ordering the agency to suspend or terminate the medical insurance service agreement, and including it in the list of Joint Disciplinary objects for dishonesty Transfer to relevant administrative departments The relevant administrative departments shall, in accordance with the violation of laws and regulations, impose administrative punishments such as ordering to suspend business for rectification, revoking the business (operation) license, revoking the qualification of practice, etc Public officials who violate the law and regulations shall be given administrative sanctions according to law If a crime is constituted, criminal responsibility shall be investigated according to law Article 28 in any of the following circumstances,
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