The State Health Insurance Administration issued a document to strictly investigate 15 medical violations involving all medical institutions and persons

Recently, the State Health Insurance Administration issued the "Medical Security Administrative Law Enforcement Matters Guidance Directory" (hereinafter referred to as the "Directory").
, the National Health Insurance Administration released the List of Administrative Enforcement Matters (2020 edition).
, the "list" has been upgraded to a "catalog", with clearer and more comprehensive regulatory content and increased regulation.
The Directory lists 15 types of health insurance law enforcement priorities, of which the main aspects of medical institutions are the following: Strengthening supervision of medical service behavior and expenses The Directory supervises and manages medical service behavior and medical expenses that are included in the scope of payment of the Basic Medical Insurance Fund in accordance with the Basic Health Care and Health Promotion Law issued last year.
article 87 of the Basic Medical and Health Promotion Law: The competent department of medical security of the people's government at or above the county level shall improve the capacity and level of medical security supervision, strengthen supervision and management of medical service acts and medical expenses included in the scope of payment of the basic medical insurance fund, and ensure the rational use and safe control of the basic medical insurance fund.
to severely crack down on the act of defrauding medical insurance shall punish medical insurance operators and medical insurance service institutions such as medical institutions and pharmaceutical business units for fraudulently, falsifying supporting materials or other means to defraud medical insurance and maternity insurance funds.
article 87 of the Social Insurance Law: If a social insurance agency and a social insurance service institution such as a medical institution or a pharmaceutical business unit fraudulently obtain the expenditure of the social insurance fund by fraud, forgery of supporting materials or other means, the administrative department of social insurance shall order the return of the fraudulent social insurance funds and shall be fined between two and five times the amount of the fraud.
Article 104 of the Basic Medical and Health Promotion Law: If the basic medical insurance operators and medical institutions and pharmaceutical business units fraudulently obtain the expenditure of the basic medical insurance fund by fraud, forgery of supporting materials or other means, the competent department of medical security of the people's government at or above the county level shall, in accordance with the relevant laws and administrative regulations on social insurance, give administrative penalties.
Article 25 of the Social Insurance Law of the People's Republic of China: If a medical institution, a pharmaceutical business unit or other social insurance service institution fraudulently obtains the expenditure of the social insurance fund by fraud, forgery of supporting materials or other means, the administrative department of social insurance shall order the return of the fraudulent social insurance fund and impose a fine of between two and five times the amount of the fraud.
to strengthen the punishment of medical institutions for fraudulent insurance, such as violation of the drug price management policy as a means to cheat the medical insurance fund expenditure punishment.
article 87 of the Social Insurance Law: If a social insurance agency and a social insurance service institution such as a medical institution or a pharmaceutical business unit fraudulently obtain the expenditure of the social insurance fund by fraud, forgery of supporting materials or other means, the administrative department of social insurance shall order the return of the fraudulent social insurance fund and shall be fined between two and five times the amount of the fraudulent scheme;
to crack down on fraud, forgery of supporting materials or other means to obtain medical insurance, maternity insurance treatment punishment.
Article 88 of the Social Insurance Law: Whoever defrauds social insurance benefits by fraud, forgery of supporting materials or other means shall be ordered by the administrative department of social insurance to return the social insurance benefits obtained by deception and shall be fined between two and five times the amount of the fraud.
article 104 of the Basic Medical and Health Promotion Law: In violation of the provisions of this Law, the competent department of medical security of the people's government at or above the county level shall, in accordance with the provisions of the relevant laws and administrative regulations on social insurance, give administrative penalties for fraudulently, falsifying supporting materials or other means.
" to combat the act of defrauding medical aid funds to take false reports, concealment, forgery and other means to cheat medical aid funds punishment.
Article 68 of the Interim Measures for Social Assistance (Order Of the State Council of the People's Republic of China No. 649): If a social assistance fund, material or service is fraudulently reported, concealed or forged, the relevant departments shall decide to stop social assistance and order the return of the illegally obtained relief funds or materials, and may be fined between 1 times or less than 3 times the value of the illegally obtained relief funds or materials.
The actual purchase and sale price and quantity of medicines shall be examined and inspected by the licensed holders of medicines, pharmaceutical and medical supplies production enterprises, pharmaceutical enterprises and medical institutions to provide the competent departments of pharmaceutical prices with information on the actual purchase and sale prices and quantities of their medicines and medical supplies.
86 of the Drug Administration Law: Drug market license holders, pharmaceutical production enterprises, pharmaceutical enterprises and medical institutions shall, in accordance with law, provide the competent department of drug prices with information on the actual purchase and sale price and quantity of their drugs.
inspection of drugs and high-value medical supplies centralized procurement of public medical institutions drugs and high-value medical supplies centralized procurement behavior compliance supervision and inspection.
the implementation of the Directory is based on the Provisions on Functional Configuration, Institutional Setting and Staffing of the competent departments of medical security at all levels.
In April, the State Health Insurance Administration issued the "List of Administrative Law Enforcement Matters (2020 Edition)" mentioned that the "State Health Security Administration functional allocation, internal institutions and staffing provisions" provides that: the State Health Insurance Administration to formulate drugs, medical supplies tender procurement policy and supervision and implementation, guide the construction of pharmaceutical, medical supplies tender procurement platform.
the implementation of disciplinary measures against medical institutions, personnel and other credit records system, into the national credit information sharing platform, its acts of dereliction of trust in accordance with the provisions of the State to implement joint punishment.
article 93 of the Basic Medical and Health Promotion Law: The competent departments of health and health of the people's governments at or above the county level and the competent departments of medical security shall establish credit records systems for medical and health institutions and personnel, incorporate them into the national credit information sharing platform, and implement joint disciplinary measures in accordance with the provisions of the State.
31 of the Social Insurance Audit Law: Social insurance agencies may, in accordance with the needs of administrative services, sign service agreements with medical institutions and pharmaceutical business units to regulate the conduct of medical services.
medical institutions shall provide reasonable and necessary medical services to the insured personnel.
Article 2 of the Measures for Social Insurance Audit (Order No. 16 of the Ministry of Labour): The audit referred to in these Measures refers to the verification conducted by social insurance agencies in accordance with the law on the payment of social insurance premiums and the collection of social insurance benefits.
: Social insurance agencies at or above the county level are responsible for social insurance audit work.
article 5: Social insurance agencies and social insurance auditors carry out audit work and exercise the following functions and powers: (1) require the audited unit to provide employment, wage income, financial statements, statistical statements, payment data and related books of account, accounting vouchers, etc. and pay social insurance premiums Relevant information and information; (2) the information relating to the payment of social insurance premiums may be recorded, recorded, recorded, recorded, photographed and reproduced, the information of the subject under audit and the payment of social insurance premiums may be investigated and inquired about, and (3) the subject under audit may be required to provide information relating to the audit matters. article
Article 12: If the social insurance agency shall verify the status of the social insurance treatment received by the insured individual and find that the recipient of the social insurance treatment continues to receive the treatment or other forms of fraudulent social insurance treatment after he or she has been disqualified from receiving the treatment, the social insurance agency shall immediately stop the payment of the treatment and order the refund.