In order to strengthen the construction of intelligent audit and monitoring knowledge bases and rule bases (hereinafter referred to as "two databases") of medical security funds, improve regulatory efficiency, and promote safe, efficient, and rational use of funds, the National Medical Security Administration announced today (15th) "Medical Security Fund Intelligent Audit and Monitoring Knowledge Base and Rule Base Framework System (Version 1.0)".
In addition to accountability and punishment after the event, medical insurance fund supervision also actively promotes intelligent audit and monitoring. The medical insurance department uses the intelligent supervision system of pre-reminder, mid-event early warning, and post-event review to move the fund supervision gate forward, automatically intercept "clear violations" behaviors, and prompt "suspicious" behaviors that violate fair use rules. This requires a knowledge base and The rule base is used as the basis for judgment.
In the framework system version 1.0 of the national "two databases", the knowledge base includes three types of knowledge catalogs: policy, management, and medical, including laws, regulations and policy norms, medical insurance information business codes, medical knowledge, management norms, etc. . The rule base is divided into policy category (30 items), management category (28 items), and medical category (21 items), including a total of 79 rules. In accordance with the requirements of the "Two Banks" Management Measures, the National Medical Security Administration publicly releases the framework content of the "Two Banks" to the public, and the medical insurance agency uses the "Two Banks" to carry out payment audits, agreement assessments, verification audits, etc. of medical insurance settlements Business management activities; medical security administrative departments and institutions engaged in medical insurance administrative law enforcement use the "two databases" to assist in activities related to medical insurance administrative supervision and administrative law enforcement; designated medical institutions are encouraged to use the "two databases" to strengthen internal management and standardize medical service behavior.
The "two databases" of national medical insurance give full autonomy to local medical insurance departments
The "two databases" are the core of intelligent audit and monitoring work, and their quality is directly related to the effectiveness of the application of the intelligent supervision subsystem. Before the launch of the national medical insurance information platform, the number of self-built smart monitoring rules ranged from dozens to hundreds, and the amount of knowledge ranged from tens of thousands to millions. The lack of authority and practicability of the "two databases" is not conducive to the further function of intelligent audit and monitoring.
At the national level, strengthen the management of rule-making norms and rule systems, give local medical insurance departments full autonomy, and set parameters, indicators, and thresholds independently under the framework of the national "two databases" system combined with local actual supplementary rules and knowledge , application scenarios, etc. Under the framework of national rules, medical insurance departments in various places fully solicit opinions from medical institutions, and combine local medical insurance policies and fund regulatory objectives to set parameters, indicators, thresholds, application scenarios, etc. of the rules. In the online use of the rules, it is gradual and dynamic to ensure orderly and smooth operation. In practical application, further test the scientificity, rationality and effectiveness of the rules, and timely evaluate and adjust them. Encourage designated medical institutions, industry associations, etc. to actively propose knowledge information or corresponding rules that meet the requirements of the standards and have universal significance in accordance with national policies and standards.
The construction of "two databases" respects the opinions and suggestions of medical institutions
In version 1.0 of the framework system, the construction of the "two databases" pays attention to the relationship between following medical laws and appropriate and reasonable intervention. The "two databases" rules include policy, management, and medical rules. Different rules have different operating logic, regulatory objectives, and effect strengths. Supervision and intervention should be strengthened for illegal diagnosis and treatment; for rules involving medical rationality, local medical insurance departments should fully listen to the opinions and suggestions of medical institutions when demonstrating and applying them. Specifically, among the 79 rules, the operation result of violating policy restrictions is "clear violation", which realizes automatic interception of violations of laws and regulations; violation of fair use rules, the operation result is mostly "suspicious", and medical institutions need to fully listen to the results. Determine whether to pay after the appeal. Medical insurance departments at all levels should establish and improve management mechanisms, formulate procedures for handling suspicious information, strengthen communication with medical institutions, and properly handle complaints from medical institutions.
Intelligent supervision does not affect the normal medical treatment of insured persons
Generally speaking, the medical insurance department strengthens the supervision of medical insurance funds through intelligent supervision methods. The fundamental purpose is to protect the people's "medical money" and "life-saving money", and fundamentally protect the rights of insured people to see a doctor. On the one hand, the insured person needs to go through identity identification to see a doctor, and the real-name medical treatment and drug purchase system is strictly implemented to ensure that the witnesses and certificates match. Behavior has an impact. On the other hand, the intelligent supervision system regulates the diagnosis and treatment behavior of designated medical institutions through the operation of rules, reminds medical personnel of unreasonable diagnosis and treatment, inspection, and prescribing behaviors in real time, and guides medical personnel to consciously abide by clinical diagnosis and treatment norms and medical insurance management policies. Provide medical services in a compliant and reasonable manner, ensure the safe, efficient and rational use of medical insurance funds, and protect the rights and interests of insured persons to enjoy standardized medical services.
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