The General Office of the State Council has issued guidance on the reform of the system of supervision of the medical insurance fund.

On July 9, the General Office of the State Council issued guidance on promoting the reform of the system of supervision of the medical security fund.
mentions deepening the reform of the payment method of medical insurance and strengthening the fund's budget management and risk warning.
establish a list management system for medical security treatment, determine the connotation of basic security, clarify the payment boundary of treatment, and clarify the authority of policy adjustment.
strengthen the incentive and restraint role of medical insurance for medical and pharmaceutical, strengthen the overall regional supervision responsibilities, and optimize the fund supervision work basis.
also includes deepening the supply-side reform of medical services. The main content of the
is to speed up the comprehensive reform of public hospitals, establish and improve the modern hospital management system, and standardize the behavior of diagnosis and treatment.
regulate the promotion of appropriate medical technologies around common and health problems.
constantly improve the market-led drug, medical supplies price formation mechanism, improve the medical insurance payment and tender procurement price linkage mechanism.
strengthen the quality supervision and inspection of accounting information in the pharmaceutical industry, and carry out in-depth special treatment of inflated prices of pharmaceutical and high-value medical supplies.
also includes deepening the supply-side reform of medical services. The main content of the
is to speed up the comprehensive reform of public hospitals, establish and improve the modern hospital management system, and standardize the behavior of diagnosis and treatment.
regulate the promotion of appropriate medical technologies around common and health problems.
constantly improve the market-led drug, medical supplies price formation mechanism, improve the medical insurance payment and tender procurement price linkage mechanism.
strengthen the quality supervision and inspection of accounting information in the pharmaceutical industry, and carry out in-depth special treatment of inflated prices of pharmaceutical and high-value medical supplies.
attached to the guidance of the General Office of the State Council on the reform of the system of supervision of medical security funds (State Office issued No. 20) the people's governments of provinces, autonomous regions and municipalities directly under the Central Government, ministries and agencies under the State Council: the Medical Security Fund (hereinafter referred to as the Medical Insurance Fund) is the people's "medical money" and "life-saving money", and the CPC Central Committee and the State Council attach great importance to the safety of the medical insurance fund. Since the establishment of the basic medical security system
, the coverage has been expanding and the level of protection has been steadily raised, which has played a positive role in safeguarding the people's health rights and interests, alleviating poverty due to illness, and promoting the reform of the medical and health system.
especially in the process of combating the outbreak of new crown pneumonia, timely introduction of relevant policies, the new crown pneumonia diagnosis and treatment into the scope of medical insurance fund payment and advance part of the funds, to ensure that patients do not affect the cost of medical treatment, hospitals not due to payment policy impact treatment, reflects the superiority of our socialist system.
but also to see that the regulatory system system is not perfect, incentive and restraint mechanism is not perfect and other factors, the use of medical insurance funds is not efficient, fraud and insurance problems are frequent, the fund supervision situation is more serious.
in order to comprehensively improve the ability of medical insurance governance, deeply purify the operating environment of the system, strictly observe the fund security red line, with the consent of the State Council, is now on the promotion of the reform of the system of supervision of the medical insurance fund put forward the following views.
, the overall requirements (a) guiding ideology.
guided by Xi Jinping's new era of socialist ideology with Chinese characteristics, comprehensively implement the spirit of the 19th National Congress and the 19th Central Committee of the Cpc, the Third, Fourth and Fourth Plenary Sessions, in accordance with the decision-making and deployment of the CPC Central Committee and the State Council, accelerate the reform of the system of supervision of the medical insurance fund, build a comprehensive and all-process fund security prevention and control mechanism, crack down on fraud and insurance, safeguard social equity and justice, and continuously improve the people's sense of access, and promote the healthy and sustainable development of China's medical security system.
(ii) the basic principles.
adhere to the improvement of the rule of law, supervision according to law, to ensure that the fund supervision is legal and compliant, fair and just.
adhere to the government-led, social governance, and create a new pattern of fund supervision work.
adhere to reform and innovation, coordination and efficiency, and continuously improve the fund's regulatory capacity and performance.
adhere to discipline and breach of trust, encourage integrity, guide the supervision of the object to enhance self-discipline awareness, and create a good atmosphere.
(iii) the main objective.
to 2025, basically complete the system of supervision system and law enforcement system of medical insurance fund, form a comprehensive regulatory pattern based on the rule of law, credit management, multi-form inspection, big data supervision, party committee leadership, government supervision, social supervision, industry self-discipline, personal trustworthiness, and realize the rule of law, specialization, standardization, normalization and improvement of medical insurance fund supervision.
Second, clarify the regulatory responsibilities (iv) to strengthen the leadership of the Party.
adhere to and strengthen the overall leadership of the Party, and constantly improve the health insurance fund supervision of the Party building work leadership system and working mechanism.
urge medical security departments and fixed-point medical institutions to effectively strengthen the construction of grass-roots Party organizations, give full play to the role of the Party organization's battle fortress and the role of the Party member's vanguard model.
improve the supervision and restraint mechanism of the leadership team and the leading personnel of public fixed-point medical institutions, especially the principal person in charge, strengthen the supervision and assessment and accountability of their political responsibilities and fund supervision responsibilities, and build up the regulatory bottom line.
(v) strengthen government supervision.
give full play to the leading role of the government in fund supervision and rule of law construction, standard-setting, administrative law enforcement, information sharing, supervise and manage the medical service behavior and medical expenses included in the scope of medical insurance payment in accordance with the law, standardize the business of medical insurance operation, investigate and punish violations of laws and regulations in accordance with the law, strictly legal lying, and increase penalties.
strengthen the responsibility of the medical security department for the supervision of the fund, and effectively play a regulatory role.
establish a mechanism for fund supervision led by the medical security department and with the participation of relevant departments, and coordinate the work of the fund to supervise major actions and investigate and prosecute major cases.
develop a list of responsibilities and responsibilities to clarify the regulatory responsibilities of the health insurance fund.
(vi) promote self-regulation of the industry.
actively promote the development of medical and health industry organizations, guide and support its better role in the formulation of management norms and technical standards, standard practice and management services, and promote industry self-discipline.
fixed-point pharmaceutical institutions should effectively implement the responsibility of self-management subjects, establish and improve the internal management mechanisms of medical insurance services, human resources, finance, system security, fulfill the industry self-discipline conventions, and consciously accept medical insurance supervision and social supervision.
. To promote the reform of the regulatory system (7) to establish and improve the supervision and inspection system.
the implementation of a "double random, one open" supervision mechanism, the establishment and improvement of daily inspection, special inspection, flight inspection, key inspection, expert examination and other combination of multi-form inspection system, clear inspection objects, inspection focus and inspection content.
regulate start-up conditions, work requirements and work processes, clarify the rights and obligations of all parties, and ensure openness, fairness and fairness.
set up a departmental linkage mechanism, carry out joint inspection, form a regulatory joint force.
actively introduce third-party forces such as information technology service institutions, accounting firms and commercial insurance institutions to participate in the supervision of medical insurance funds, establish and improve the government purchase service system, implement pay-per-service performance, and enhance the professionalism, precision and efficiency of supervision.
(viii) establish a comprehensive intelligent monitoring system.
accelerate the standardization and informationization of medical insurance, strictly implement the requirements of integrated and sharing of government information systems, do a good job of connecting with the original relevant systems, strengthen the exchange and sharing of information between departments, and avoid duplication of construction.
establish and improve the intelligent monitoring system of medical insurance and strengthen the application of big data.
strengthen the guidance and examination of clinical practice behavior in fixed-point medical institutions, and strengthen the supervision in advance and in the event. in view of the characteristics of fraudulent insurance practices, the
has continuously improved the medical knowledge base, such as basic information standards libraries and clinical guidelines, such as drugs, medical treatment projects and medical service facilities, and improved the rules of intelligent monitoring and enhanced intelligent monitoring functions.
to carry out real-time management of the purchase and sale of pharmaceutical and medical supplies.
promote technology applications such as video surveillance and biometrics.
promote the immediate settlement of medical treatment and purchase of medicines in different places, so as to realize the full on-line settlement data.
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.
(9) establish and improve the reporting reward system.
the overall area and above the medical security and financial departments shall establish and constantly improve the system of reward selling violations of laws and regulations in medical security, and reward whistleblowers in accordance with relevant provisions.
open channels for reporting complaints, standardize the processing and mechanisms for receiving, inspecting, handling and feedback, strengthen privacy protection, and effectively safeguard the information security of whistleblowers.
improve the standard of reporting incentives, timely cash reward funds, and promote the active participation of the masses and all parties in society in supervision.
(10) establish a credit management system.
establish a system for reporting information on fixed-point medical institutions.
establish the medical insurance credit records, credit evaluation system and points management system for medical institutions and insured personnel.
the comprehensive performance evaluation mechanism of innovative fixed-point pharmaceutical institutions, and associate the credit evaluation results with the results of comprehensive performance evaluation with budget management, inspection audit, fixed-point agreement management, etc.
strengthen and standardize the management of the list of trustworthy joint incentive objects and joint disciplinary objects in the field of medical security, and implement joint incentives and breach of trust in accordance with the law.
encourage industry associations to carry out industry norms and self-discipline, formulate and implement self-discipline conventions, and promote industry norms and self-restraint.
(11) to establish a comprehensive regulatory system.
adapt to the characteristics of medical insurance management services, establish and improve the comprehensive supervision system of inter-departmental cooperation and coordination supervision, and implement grid management.
promote information sharing and connectivity, and improve the work mechanism of coordinated law enforcement.
to the investigation of fraud and insurance fraud, the relevant departments shall, in accordance with the provisions of laws and regulations and the authority of responsibility and authority, strictly deal with the units and individuals concerned.
establish and improve the mechanism of bridging the working mechanism to combat fraud and fraud and execution. the
medical security department shall be responsible for supervising and supervising the medical service behavior and medical expenses included in the scope of medical insurance payment, regulating the business of medical insurance operation, and investigating and prosecuting violations of laws and regulations in the field of medical security in accordance with the law.
health departments are responsible for strengthening the supervision of medical institutions and medical service industries, regulating the medical services of medical institutions and their medical personnel.
market regulatory department is responsible for the price supervision and inspection of the medical and health industry, the drug regulatory department is responsible for the management of the practicing pharmacist, the market regulatory department and the drug regulatory department are responsible for the supervision of drug circulation and regulate the operation of the drug in accordance with the division of duties.
audit ingons are responsible for strengthening the implementation of relevant policies and measures related to the supervision of medical insurance funds, urging relevant departments to fulfill their regulatory duties, pay ingon to all kinds of fraud and insurance issues, and promptly transfer them to relevant departments for investigation and punishment.
public security departments are responsible for investigating and punishing all kinds of criminal acts such as fraud and insurance fraud in accordance with the law, and conducting timely investigations into suspected crimes transferred.
other relevant departments to do the relevant work in accordance with their duties.
(12) improve the system of social supervision.
encourage and support all sectors of the community to participate in the supervision of the medical insurance fund, and realize the positive interaction between government supervision and social supervision and public opinion supervision.
establish an information disclosure system.
agencies regularly announce to the community the income and expenditure, balance and income of the fund, and accept social supervision.
establish a system of social supervisors of medical insurance funds, employ deputies to the National People's Congress, members of the CPPCC, the masses and representatives of the media as social supervisors, and conduct extensive and in-depth supervision over designated medical institutions, operating institutions and insured personnel.
actively invited the news media to participate in flight inspection, inspection and covert visits and other work, through press conferences, media ventilation and other forms, issued to combat fraud and insurance results and typical cases.
. Improve safeguardmeasures (13) to strengthen the rule of law and standardized protection of the supervision of medical insurance funds.
formulate regulations on the supervision and management of the use of medical security funds and their supporting measures.
improve the agreement management system of fixed-point medical institutions, establish and improve the dynamic management and exit mechanism of fixed-point medical institutions.
improve the monitoring mechanism of medical insurance on medical service behavior, extend the supervision object from medical institution to medical personnel, and shift the supervision focus from medical expense control to medical cost and medical service performance double control.
the introduction and implementation of medical and health industry standards, and gradually carry out clinical path management, improve and implement the system of clinical pharmacists, prescription evaluation system, strengthen clinical application and evaluation of standards and standardized application.
(14) strengthen the capacity of supervision and inspection of medical insurance funds.
strengthen the capacity-building of the fund supervision and inspection, establish and improve the fund supervision and enforcement system, strengthen the strength of personnel, strengthen technical means.
straighten out the relationship between the administrative supervision of medical insurance and the management of the management of the operating agreement, clarify the boundary of the duties of administrative supervision and the audit, and strengthen the link between the work.
the implementation of the agency agreement management, cost monitoring, audit and audit work responsibilities.
establish and improve the internal control system of the operating institutions, regularly employ third-party institutions to assess the internal control risks of the operating institutions, and build up the internal control line of the fund supervision.
strengthen the security of financial resources at all levels and strengthen the supervision of the Fund through the purchase of government services.
the personnel, equipment and related facilities necessary to guarantee the provision of medical security services by medical institutions.
(15) increase penalties for fraudulent insurance.
comprehensive use of judicial, administrative, agreement and other means to severely punish units and individuals who cheat and defraud.
strictly implement the legislative interpretation of the Standing Committee of the National People's Congress on fraud and insurance fraud, and transfer cases of suspected crimes to judicial organs for criminal responsibility in accordance with the law.
the medical security departments shall increase the administrative penalties in accordance with the law.
actively play the role of joint punishment by the department, the health and health, drug regulatory departments shall, in accordance with the law, impose penalties such as suspension of business and rectification, revocation of qualifications for practice (operation) and restrictions on practice, and enhance the deterrent effect of punishment for designated pharmaceutical institutions that have been verified by the medical security department and have committed fraud and insurance fraud.
to include the list of persons of joint disciplinary action for fraud and insurance fraud, and to implement joint disciplinary measures.
(16) to comprehensively promote the reform of the relevant medical security system.
deepen the reform of the payment method of medical insurance and strengthen the fund budget management and risk warning.
establish a list management system for medical security treatment, determine the connotation of basic security, clarify the payment boundary of treatment, and clarify the authority of policy adjustment.
strengthen the incentive and restraint role of medical insurance for medical and pharmaceutical, strengthen the overall regional supervision responsibilities, and optimize the fund supervision work basis.
(17) work together to promote the reform of the medical service system.
deepen the supply-side reform of medical services.
speed up the promotion of public.