In order to thoroughly implement the decision-making and deployment of the Party Central Committee and the State Council, give full play to the role of medical insurance fund supervision in the anti-corruption "searchlight" in the medical field, severely crack down on various violations of laws and regulations in the medical insurance field, and resolutely guard the people's "medical money" and "life-saving" money", in accordance with the requirements of the "Notice of the National Medical Insurance Administration, the Ministry of Finance, the National Health and Health Commission, and the State Administration of Traditional Chinese Medicine on Carrying out Unannounced Inspections of Medical Security Funds in 2023", starting from August this year, the four departments will jointly organize and carry out medical insurance covering 31 provinces across the country. (autonomous regions, municipalities directly under the Central Government) and the Xinjiang Production and Construction Corps' medical security fund unannounced inspections.
The unannounced inspection of the National Medical Insurance Fund in 2023 was officially launched today in Bijie, Guizhou.
The unannounced inspection is mainly aimed at three aspects.
1. For designated medical institutions. Including the internal control management of medical insurance, financial management, the implementation of centralized procurement of medicine consumption, the application of the national unified medical insurance information business code, and the medical service behavior and charging behavior involved in the use of medical insurance funds. Focus on three areas: medical imaging examination, clinical examination, and rehabilitation.
Second, for retail pharmacies. Including the replacement of drugs or other commodities that are not paid by the medical insurance fund into medical insurance drugs, empty or stolen medical insurance certificates, forgery or alteration of medical insurance drug purchase, sales and deposit receipts and accounts, and forged prescriptions or insured personnel's expense lists. Settlement of medical insurance expenses by designated retail pharmacies, designated retail pharmacies or other institutions during the termination of medical insurance agreements.
3. Check the internal control management of medical insurance agencies. Including the daily review, payment and verification of the expenses declared by designated medical institutions and insured persons, the determination of the annual budget under the DRG/DIP payment method, the use of the intelligent review system, etc.
Since the establishment of the National Medical Insurance Bureau, it has promoted the full coverage of daily supervision for five consecutive years. The reporting reward system has initially established a high-pressure situation to combat fraud and insurance fraud. As of June 2023, a total of 3.579 million designated medical institutions have been inspected, 1.703 million times have been processed, and 83.5 billion yuan in medical insurance funds have been recovered.
According to the National Medical Insurance Administration, the current regulatory situation of my country's medical insurance funds is still severe and complicated. There are more than 950,000 medical insurance regulatory institutions nationwide. Currently, the national unified medical insurance information platform has an average daily settlement volume of about 18 million person-times, and the highest daily settlement volume is about 34.76 million person-times. Faced with so many regulatory objects and the use of medical insurance funds, the National Medical Insurance Bureau has continued to explore and practice, and has accumulated some effective regulatory experience.
The first is to combine points, lines and areas to promote the normalization of unannounced inspections, special rectifications, and daily supervision. Among them, the unannounced inspection focuses on the point, the special rectification focuses on the line, and the daily supervision focuses on the surface. These three are organically combined and complement each other.
The second is to combine on-site and off-site to promote the normalization of intelligent monitoring. Intelligent monitoring of medical insurance is one of the important measures to solve the pain points and difficulties of supervision. Through the popularization and application of intelligent monitoring, it is possible to realize the whole-process prevention and control of the front-end reminder of the hospital, the review in the handling process, and the post-event supervision of the administrative side. In 2022, the country will reach 3.85 billion yuan in medical insurance fund refusal and recovery through intelligent monitoring.
The third is to combine government supervision and social supervision to promote the normalization of social supervision. The National Medical Insurance Bureau has always been committed to creating a fund supervision atmosphere where the whole society participates, constantly improving the social supervision system, smoothing the reporting and complaint channels, and comprehensively promoting the implementation of the reporting reward system. Since 2018, the National Medical Insurance Bureau alone has received more than 36,000 clues for various reports and complaints. According to the clues, the country has recovered a total of about 1.7 billion yuan in funds, and the country has accumulatively cashed out about 7.19 million yuan in rewards for reporting. At the same time, it pays attention to the exposure of typical cases. As of June this year, a total of 267,000 typical cases have been exposed across the country, sending a strong signal of a zero-tolerance attitude to severely crack down on fraudulent insurance fraud and other illegal activities, and has achieved a good warning and deterrent effect.
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