Strictly Abide By The "Gate" Of Medical Insurance Fund: Implementing New Regulations To Combat Fraud

Since June 1st, the new regulation for the supervision of medical insurance in Shanghai, the basic medical insurance supervision and administration measures in Shanghai, has been formally implemented. Since then, the legal responsibilities of fraudulent and fraudulent practices and other illegal activities have become clearer, and the intensity of punishments will continue to be strengthened. The Interim Measures for the administration of credit in the field of medical insurance in Fujian issued by the medical insurance bureau of Fujian province are also implemented from June 1st.

Since the establishment of the national health insurance agency, cracking down on fraud and fraud has been one of the key tasks. In March 30th, the national health insurance agency released the "2019 medical security development statistics bulletin" shows that the medical insurance departments at all levels on-site inspection of a total of 81.5 medical institutions, investigate and deal with illegal and illegal medical institutions 26.4, 000, in 2019, a total recovery of 11 billion 556 million yuan.

Shao Xiaojun, chief medical officer of the Pacific health insurance health care center, pointed out to the twenty-first Century economic report reporter that with the development of population aging, the expenditure pressure of medical insurance funds will be bigger and bigger. The National Health Insurance Department urgently needs to upgrade the regulatory system and increase the crackdown on fraud and fraud. In addition, Hu Jiqiang, chairman of the Jiangxi group, and Mei Yi, director of the medical insurance bureau of the province, suggested that the national laws and regulations on health care should be improved as soon as possible.

Introduce new regulations

The "basic medical insurance supervision and management measures of Shanghai", which began in June 1st, are applicable to designated medical institutions, designated retail pharmacies, individuals and designated institutions of long-term care insurance. And the number of medical treatment, medical insurance costs and so on should be monitored in real time.

Among them, cheating the basic medical insurance fund expenditure by designated medical institutions or designated retail drugstores, and cheating the medical insurance by the insured or other individuals, there are unverified medical insurance vouchers, illegal fees, allowing non registered doctors to engage in medical services and other behaviors. A clear penalty provision.

At the same time, Shanghai medical insurance bureau also said that we should establish and improve the medical insurance credit evaluation system and information disclosure system. We should collect and dismiss the designated medical institutions, designated retail pharmacies, designated assessment institutions and designated nursing institutions and their staff members, insured personnel and other individuals according to the relevant provisions of the state and the city, and carry out joint disciplinary actions in accordance with the law.

Coincidentally, in May 29th, the Fujian Provincial Health Insurance Bureau issued the Interim Measures for credit management in the Fujian medical insurance field, which was implemented in June 1st, and clearly stipulates that the medical expenses that should not be paid by the medical insurance fund will result in the loss of more than 3000 yuan (inclusive) of the medical insurance fund, and the inconsistency of hospitalization orders, treatment sheets, inspection reports and disease records, resulting in the loss of the medical insurance fund. More than 6000 yuan (inclusive), the above behavior suspended medical insurance service personnel medical insurance services for 6 months, the media publicly announced, transferred to the health sector to deal with.

According to the twenty-first Century economic report reporter, in order to safeguard the fund safety and establish a long-term mechanism to effectively curb the medical insurance payment of illegal medical services, the Heilongjiang medical insurance bureau has decided to organize the province's agencies at all levels to carry out special inspections on the medical services designated by the medical insurance designated medical institutions since May 29th.

As early as April 28th, the Beijing Medical Security Bureau also issued a notice on the work of cracking down on fraud and fraud in 2020, and formulated a special work plan for the designated medical institutions in Beijing to crack down on fraud and swindling medical insurance funds in 2020.

From the above new regulations, we can see that the local health insurance bureaus are targeting medical institutions, drugstores and other fraudulent practices. The head of a local health insurance bureau told the economic news reporters twenty-first Century that they had investigated various fraudulent practices, such as using counterfeit cases, hanging beds, and other means to acquire medical insurance funds.

At the two sessions of the National People's Congress this year, the deputy to the National People's Congress and the director of the Jiangxi provincial health insurance bureau also pointed out that the security situation of the medical insurance fund is still grim, fraudulent and fraudulent insurance is prone to occur frequently, and there are many problems such as changing items, overcharging and over diagnosis. The contradiction between insufficient strength and limited supervision means is particularly prominent. It is urgent to further improve the supervision system of medical insurance fund.

Throttle control fee

The supervision of medical insurance fund is an important task of the national health insurance agency.

With the development of population aging, the expenditure pressure of medical insurance funds will be bigger and bigger.

After the establishment of the national health insurance agency, the reform of heavy purchase with quantity purchase, drug price negotiation, medical insurance catalog adjustment and so on was successively presented. At the same time, the national health insurance departments urgently need to upgrade the supervision system, increase the crackdown on fraud and fraud, and are "cutting the throttle" for the medical insurance fund.

Shao Xiaojun pointed out to the twenty-first Century economic report reporter that the DRG payment reform currently launched by the national health insurance bureau can fundamentally solve the problem of hospitalization fraud.

"DRG payment will force medical institutions and doctors to change the past project based excessive medical behavior, and change the standardized medical behavior guided by the clinical pathway to cost control, so that medical institutions and doctors can achieve the goal of controlling the growth of hospitalization expenses through independent behavior.

Zhu Fengmei, Assistant Research Fellow of the policy research center of the Ministry of civil affairs, said that for a long time, due to the imperfect legal system, imperfect supervision mechanism, relatively extensive supervision mode and serious shortage of supervision power, the occurrence of chaos such as "fraud" and "fraud insurance" has affected the safe operation and sustainable development of the medical insurance fund for a long time.

It is understood that due to the lack of corresponding laws and regulations for medical insurance supervision in China, most of them are supervised according to the agreements signed.

To this end, this year's NPC and CPPCC National Committee, Hu Jiqiang, chairman of the National Committee of the people's Republic of China, told the twenty-first Century economic news reporter that the formulation of laws and regulations on the national level of medical insurance should be put on the agenda as soon as possible.

"In addition to the" People's Republic of China social security law "of 2010, the basic medical insurance system has a principled standard on the legal level, and there are some local laws and regulations related to medical insurance all over the country. So far, no laws or regulations for medical insurance have been formulated at the national level. The relevant provisions of medical insurance are only scattered in various normative documents, and are not conducive to promoting medical treatment according to law. Health care. Hu Jiqiang pointed out.

Mei also said that it is necessary to speed up the establishment of a national legal system for the supervision of medical insurance funds at the national level, standardize the powers of supervision, procedures, and punishment standards, so as to realize laws and law enforcement grounds.

"It is suggested that the law and Work Commission of the Standing Committee of the National People's Congress shall timely incorporate the basic medical insurance law into the legislative planning plan, and make amendments to the social insurance law. It is suggested that the Ministry of justice speed up the legislative process of the regulations on the supervision and Administration of the use of medical insurance funds. Mei also said.

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