"Two pilot and one demonstration" of health insurance fund supervision

Notice on carrying out the work of "two pilot and one demonstration" in the supervision of medical insurance fund (medical insurance Ban Fa [2019] No 17) Medical Security Bureau of each province, autonomous region, municipality directly under the central government and Xinjiang production and Construction Corps: In order to innovate the way of supervision, improve the efficiency of supervision and speed up the construction of a long-term mechanism of fund supervision, in accordance with the requirements of the notice of the State Medical Insurance Bureau on doing a good job in the supervision of medical insurance fund in 2019 (medical insurance Fa [2019] No 14), and recommended by the provincial (District, city) medical insurance departments and selected by the organization of the State Medical Insurance Bureau, we are now carrying out the pilot and basic innovation of fund supervision mode of the State Medical Insurance Bureau The list and work plan of the pilot project of gold regulatory credit system construction and medical insurance intelligent monitoring demonstration site (hereinafter referred to as "two pilot projects and one demonstration") are printed and distributed to you Local medical insurance departments should strengthen organizational leadership, carry out relevant work in accordance with the work plan, and actively promote the formation of scalable and replicable advanced experience in the supervision of medical insurance funds The state health insurance bureau will take various forms to strengthen supervision and guidance, summarize and exchange experience and practices, and timely promote them Annex: 1 List of "two pilot and one demonstration" areas for fund supervision of the State Medical Security Bureau 2 Work plan of "two pilot and one demonstration" for fund supervision of the State Medical Security Bureau on May 21, 2019 Annex 2: work plan of "two pilot and one demonstration" for fund supervision of the State Medical Security Bureau In order to implement the decision-making and deployment of the Party Central Committee and the State Council, and the requirements of the notice of the State Medical Security Bureau on doing a good job in the supervision of medical security funds in 2019 (medical insurance Fa [2019] No 14), we will steadily promote the innovation pilot of fund supervision mode, the construction pilot of fund supervision credit system and the construction of medical insurance intelligent monitoring demonstration point (hereinafter referred to as "two pilots and one demonstration"), Develop this plan 1、 Overall requirements (1) the target task will be used for 2 years, and significant progress will be made in the innovation of regulatory methods, the construction of credit system and intelligent monitoring in pilot (demonstration site) areas, forming experiences, models and standards that can be used for reference, copied and popularized, so as to make new breakthroughs in the supervision of medical security funds （2） The first basic principle is the linkage between the top and the bottom Establish a coordination mechanism for the work of "two pilots and one demonstration", clarify the responsibilities of the state, provinces (demonstration sites) and regions (demonstration sites), and coordinate the implementation Second, multi participation Strengthen the coordination with relevant departments, and introduce social resources to participate in the pilot (demonstration site) work through various channels and forms Third, strengthen the assessment Establish and improve the performance evaluation index system of pilot (demonstration point) areas, and carry out the evaluation scientifically in combination with the actual performance of fund supervision 2、 Work content (1) pilot areas for innovation of fund supervision methods can focus on one or several aspects as follows One is to introduce social forces to participate in supervision Actively introduce third-party forces such as information technology service institutions, accounting firms, commercial insurance institutions, give full play to the role of professional and technical support, establish and improve cooperation mechanisms such as data screening, financial audit, medical record audit, etc., and achieve forward, efficient and accurate fund supervision The second is to build a mechanism of department linkage supervision Strengthen cooperation with health, public security, market supervision, drug supervision and other departments, further improve the working mechanism of unified deployment, joint inspection, case notification, case transfer, joint punishment, etc.; establish and improve the working mechanism of joint action, "multiple investigation for one case" and "multiple investigation for one case", standardize the working process; coordinate and promote the implementation of major fund supervision actions, investigation and treatment of major cases, etc To achieve seamless connection of the whole chain of fund supervision Third, other innovative supervision methods Each pilot area shall explore on its own in combination with the actual situation （2） The pilot areas of fund supervision and credit system construction can focus on one or several aspects as follows First, establish a credit evaluation index system for fund supervision To explore the construction path of fund supervision credit system, focusing on the construction of relevant standards, norms and index system, relevant information collection, evaluation and result application Second, establish a dynamic management mechanism for designated medical institutions Establish and improve the hierarchical management system of designated medical institutions and the integral management system of medical insurance doctors and medical insurance pharmacists, explore and establish the management mechanism of comprehensive performance evaluation and elimination of the last place of designated medical institutions, and regard the establishment and improvement of management system and mechanism, performance agreement, standardized and reasonable use of medical insurance funds, performance evaluation and other situations as the targeted medical institutions, medical insurance doctors and doctors The important basis for the assessment and evaluation of pharmacists is to associate the assessment results with budget management, inspection and audit, cost settlement, agreement management, etc Third, promote self-discipline in the industry Public medical institutions, non-public medical institutions, retail pharmacies, doctors, pharmacists and other industry associations are encouraged to carry out industry norms and self-discipline construction, formulate and implement self-discipline conventions, and promote industry norms and self-discipline Fourth, we will promote joint punishment We will actively promote the inclusion of fraud and deception in the local credit management system, establish a system of punishment for dishonesty, and give full play to the deterrent force of joint punishment （3） The demonstration area of medical insurance intelligent monitoring demonstration point can focus on one or several aspects as follows First, improve the intelligent monitoring function In view of the new characteristics of fraud and deception, we will improve the basic information standard database such as medical standard catalog, clinical guide and other clinical diagnosis and treatment knowledge databases, further improve different rule databases, such as diagnosis and treatment specifications, medical insurance policies, medical treatment authenticity, etc., and improve the coverage and accuracy of intelligent monitoring Second, enrich the dimension of intelligent monitoring In the regions of DRG payment pilot countries and big data based disease score payment regions, intelligent monitoring system is used to strengthen the process monitoring of clinical behaviors, enrich the analysis and comparison dimensions of big data, improve the monitoring effect; promote the application of new technologies such as video monitoring and face recognition, carry out timely management of drug purchase, sale and storage, and improve the effect Risk control system of medical insurance fund Third, establish a provincial centralized monitoring system Based on the pilot work of national medical security information system construction, the intelligent monitoring work under the provincial centralized mode is explored to continuously improve the monitoring efficiency 3、 Division of responsibilities (1) State Medical Security Bureau Determine pilot (demonstration site) areas, coordinate relevant resources as a whole, organize and establish technical guidance expert groups, and strengthen technical guidance and financial support Coordinate and manage major issues in the pilot (demonstration point) work, organize exchanges and learning among pilot (demonstration point) areas, grasp the overall progress of the pilot (demonstration point), regularly inspect and evaluate the progress of the pilot (demonstration point), and summarize the experience and effectiveness of the pilot (demonstration point) （2） Provinces of pilot demonstration sites Organize the implementation of the provincial (District, city) pilot (demonstration point) work, report the work progress to the State Health Insurance Bureau on a quarterly basis, coordinate and solve the problems and difficulties in the promotion of the pilot (demonstration point) area work, and do a good job in communication and publicity （3） Pilot demonstration area Under the leadership of the local Party committee or government, a leading group of pilot (demonstration point) work involving multiple departments shall be established to formulate the implementation plan of the pilot (demonstration point) work, regularly report the progress and effectiveness of the work, timely study and solve the problems and difficulties in the pilot (demonstration point), and solidly promote the pilot (demonstration point) work （4） Technical guidance expert group According to the unified requirements of the state health insurance bureau, we will carry out follow-up guidance, technical support, assessment and evaluation of the work in the pilot (demonstration) areas 4、 The overall schedule is divided into four stages: pilot start, pilot implementation, mid-term evaluation and summary evaluation （1） From May to June 2019, the National Health Insurance Bureau determined the list of "two pilot and one demonstration" areas, printed and issued the work notice and worked out the work plan Under the guidance of provincial medical insurance bureau, the pilot (demonstration site) areas shall formulate specific implementation plans in combination with local actual conditions, and report to the National Medical Insurance Bureau for filing before June 14 （2） Pilot implementation (June 2019 may 2021) pilot (demonstration point) areas shall carry out pilot (demonstration point) work according to the implementation plan, and report the progress, effectiveness and problems of the work in a timely manner （3） In the mid-term assessment (May June 2020), the state health insurance bureau organized the supervision, research, experience exchange, visit and investigation of the work in the pilot (demonstration point) areas, promoted mutual learning and mutual assistance in the pilot (demonstration point) areas, guided the advanced, urged the backward, and organized and expanded the construction of the pilot (demonstration point) as the case may be （4） From May to June 2021, the state health insurance bureau organized the overall assessment of the pilot (demonstration site) work, summarized and refined the advanced practices and mature experience, and popularized them 5、 Safeguard measures (1) strengthen capacity building The medical insurance departments at all levels should attach great importance to, clarify the objectives and tasks, establish and improve the working mechanism, strive for the support of all parties, and ensure the in-depth and sustainable development of the work （2） Strengthen supervision and dispatching The medical security departments in the pilot (demonstration site) areas shall promote the implementation of the work in strict accordance with the implementation plan Provincial medical security departments should strengthen the scheduling and evaluation of pilot (demonstration site) work, find out problems in time and coordinate to solve them The National Health Insurance Bureau will organize centralized research in a timely manner, and regularly inform the progress of pilot work (demonstration sites) （3） Strengthen assessment and evaluation The National Health Insurance Bureau focuses on the establishment and improvement of the organization and leadership mechanism of the pilot (demonstration point) and the mechanism of cross sector, cross industry and cross agency cooperation, the perfection of the regulatory system, the efficiency of investigation and handling of clues, and the investigation and handling of designated medical institutions, and regularly carries out assessment and evaluation, so as to promote the work of the pilot (demonstration point) to be practical and effective.