Medical insurance funds are the people’s “medical treatment money” and “life-saving money”. On the 13th, the National Medical Insurance Administration issued a notice on further promoting the intelligent review and monitoring of medical security funds, clarifying that it will implement real-time dynamic intelligent monitoring of big data, achieve full coverage of intelligent review of medical insurance fund payments, and build full-link supervision before, during and after the event. Fund security prevention and control mechanism.
The notice clearly stated that by the end of 2023, all coordinating regions will have online intelligent supervision subsystems, intelligent review and monitoring data will be accurately uploaded to the national medical insurance information platform, comprehensive intelligent review will be carried out, and "one network" for national intelligent monitoring will be initially realized; by By the end of 2025, a standardized, scientific, and normalized intelligent audit and monitoring system will be basically established, forming a normalized supervision system that handles daily audits and on-site inspections, big data analysis, full-scenario intelligent monitoring, and other methods.
The notice requires that the intelligent review and monitoring work of medical insurance funds be combined with the agreement management work, and effective measures be taken to encourage designated medical institutions to proactively connect to the intelligent supervision subsystem. The system docking status shall be linked to the annual assessment of designated medical institutions. At the same time, explore policies such as reducing the frequency of on-site inspections for medical institutions that proactively strengthen the application of intelligent supervision systems and carry out self-examination and self-correction.
According to the relevant person in charge of the National Medical Insurance Administration, in general, medical institutions can use intelligent monitoring to automatically remind and intercept obvious violations of medical personnel, and provide real-time reminders of suspected violations. At present, more and more designated hospitals are taking the initiative to use intelligent monitoring to implement self-examination and self-correction to reduce the occurrence of violations.
The person in charge said that strengthening the supervision of medical insurance funds through intelligent supervision methods will not have an impact on the normal medical treatment behavior of insured persons. For clear violations of laws and regulations, it is necessary to strengthen supervision and intervention, and gradually realize the automatic interception of violations of laws and regulations that can be rigidly restrained; for problems involving medical rationality, after the system detects doubtful problems, timely feedback must be provided to designated medical institutions. It appeals, fully listens to the appeal opinions of the medical institution, and determines whether to pay after necessary review, collegiality, final review and other procedures.
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