For the third consecutive year, the proportion of co-ordinated fund expenditure has declined.

Xin Bazaar as an old industrial base, bankruptcy-turned-enterprises, urban workers medical insurance support ratio is low, the safe operation of the health insurance fund pressure.
In order to ensure the safe operation of the medical insurance fund and protect the legitimate rights and interests of the insured persons, xin bazaar medical security bureau in accordance with the "close loopholes, strong supervision, heavy punishment, strict deterrence, build a system, long-term management" work ideas, around strengthening pre-, in-process and after-the-fact supervision, innovation and establishment". Three-control "comprehensive governance", "3-3" comprehensive supervision, "one standard three tests" comprehensive assessment of the "T-in-one" health insurance fund supervision model, comprehensively improve the long-term effectiveness of health insurance fund governance, to create a health insurance fund supervision "Xin set model."
Since 2019, Xin bazaar has investigated and dealt with 96 fixed-point medical institutions, recovered 590.51 million yuan from the denial of medical insurance funds, lifted one fixed-point medical service agreement, suspended six fixed-point medical service agreements, suspended the services of 12 medical insurance physicians, issued rectification notices to 38 fixed-point medical institutions, conducted interviews with 15 fixed-point medical institutions, and achieved full regulatory coverage.
At the same time, on the basis of ensuring a steady improvement in the level of health insurance treatment in the city, in 2017-2019, the proportion of co-ordination fund expenditure decreased by 11 percentage points over the same period of growth, for three consecutive years to achieve the current balance of the health insurance fund, and effectively maintain the safety of the health insurance fund, so that the insurance participants' sense of access, well-being, satisfaction has been continuously enhanced.
is to control in place, the implementation of "three controls and two controls" comprehensive governance.
Three-tube", that is: fixed-point medical institutions to establish a leading group of medical insurance, medical insurance department, business departments of medical insurance supervisors three-level supervision network, with the help and stimulate the fixed-point medical institutions of their own strength and endoennial motivation, to reduce the main supervision responsibility of medical institutions.
"two controls", that is: fixed-point medical institutions to carry out risk classification control and hidden trouble detection and control.
Grading control is the establishment of risk control information ledgers (lists) including risk, risk classification, control measures, responsible persons, etc. in each department of a fixed-point medical institution, and formulating risk control measures one by one according to the risk points, clarifying the control personnel and formulating the control plan.
: the first risk is the high risk point of the violation, the second risk is the risk point in the violation, and the third risk is the low risk point of the violation.
, it is the establishment of regular inspection and special inspection system for fixed-point medical institutions, the formulation of hidden trouble rectification programs and the organization and implementation, to eliminate hidden dangers.
information ledger includes the name of the hidden danger, the level of the hidden danger, the management measures, the time limit for completion, the results of the review, the responsible person and so on.
"Three-control, two-control" will be the health insurance risk control and hidden dangers management work forward, source control, and effectively play the role of the "first line of defense", and strive to promote the supervision of medical insurance funds from the supervision of the medical security sector to the medical security sector and fixed-point medical institutions supervision and re-transformation, from the treatment of the standard to the treatment of the transformation.
is to put in place supervision, the implementation of the "3 plus 3" comprehensive supervision.
the first "3", that is: the municipal medical security bureau to take the daily inspection, site inspection, special inspection three on-site inspection methods.
day-to-day inspection, is a reference to the city management grid supervision experience, the city's 511 fixed-point pharmaceutical institutions divided into four grid responsibility units, the implementation of grid management.
check the grid unit site at least once a week to ensure that problems are detected in a timely manner.
the site inspection, is to designate the grid responsible administrator to the fixed-point medical institutions to carry out the station subcontract, to ensure that the supervision and inspection does not leave a dead end.
special inspection is the regular organization of relevant departments, medical experts, third-party accounting firms, professional information technology personnel to screen suspects, drug purchase and sale, the use of consumables and other work to carry out key checks.
the second "3", that is: through intelligent monitoring, bed butler (field assistant), remote video three information monitoring platform, the construction of Xinsa market area health insurance intelligent monitoring information network.
monitoring, through strengthening the analysis of big data of medical insurance settlement, focusing on verifying whether there are duplicate charges, cross-exchange project charges and other issues.
housekeepers (field assistants), through photo transmission and mobile phone positioning, focusing on verifying whether there are problems such as hanging bed hospitalization, impersonation hospitalization.
remote video surveillance, through the pharmaceutical institutions settlement window, dialysis room and other key areas to set up high-definition video probes, timely and effective collection, locking evidence of violations of the law, forming a strong deterrent force.
"3-3" type of supervision brings together professionals and information technology, big data strong combined force, forming a "everyone has a burden, one responsibility" "up and down linkage, departmental coordination" of the three-dimensional regulatory responsibility system, so that the supervision seamless, no dead end, no blind spot, to achieve the health insurance fund supervision regular, normal, long-lasting.
is the assessment in place, the implementation of the "one standard three tests" comprehensive assessment.
"one standard", that is: to a unified two-set agreement management method as the standard, strictly review the quality of fixed-point pharmaceutical institutions, "good technology, excellent service, low price, reasonable layout" as the basic conditions for inclusion in the fixed-point medical insurance.
"three tests", that is: institutional self-assessment, medical insurance department assessment, third-party assessment three ways of assessment.
institutions self-assessment, the Municipal Medical Security Bureau will further concrete and digital content of the agreement, the organization of fixed-point medical institutions quarterly self-assessment, so that it fully understand the importance and seriousness of the medical insurance fund in the operation of hospitals, to ensure timely detection of problems, timely rectification.
The medical insurance department shall, by adopting the combination of the usual assessment and the annual appraisal, the medical insurance department and the relevant departments jointly assess, conduct the examination of the medical service behavior of the pharmaceutical institutions, the risk control of the medical insurance fund, the implementation of the agreement, etc., and continuously strengthen the awareness of compliance with the law of the designated medical institutions, standardize the service behavior, improve the quality of service, and ensure the rational use of the fund and the smooth operation of the system.
Third-party assessment, through the use of the technical strength of the third-party professional team, to take a combination of online and offline model, to extract data, intelligent audit analysis, on-site inspection and other ways to assess, accurately find the problem of violations of pharmaceutical institutions, classification summary, for the daily inspection work to provide direction and basis.
comprehensive assessment results, the two pharmaceutical institutions to carry out comprehensive ranking, good and bad classification, classification of key supervision, the amount of allocation and reward and punishment linked to continuously improve the accuracy and effectiveness of protocol management.
Next, Xin bazaar will earnestly implement the General Office of the State Council "guidance on promoting the reform of the medical security fund supervision system", strictly abide by the fund safety red line, do not forget the initial intention, keep in mind the mission, and further grasp the Xin market medical security work, especially the operation of the health insurance fund supervision work.
First, to further strengthen the classification and investigation, according to medical institutions, payment methods, medical insurance functions, etc. classification, adhere to the investigation and prosecution of fraudulent insurance fraud to the inspectors waste of health insurance funds and fund use benefits, and gradually from the main investigation and punishment of illegal acts to investigate and punish violations of the extension, from deep work to classification and investigation, and further enhance the level of supervision; At the same time, the supervision is gradually extended to hospital doctors and insured persons to further standardize the behavior of the supervised population, and the third is to further improve the system of supervision mechanism, and to form a strict, strong and effective supervision system by improving the mechanism of intelligent monitoring of information technology, credit disciplinary system, comprehensive supervision and joint law enforcement, so as to further realize all-round supervision, effectively strengthen the supervision responsibility of the fund, enhance the supervision capacity, and hand over a satisfactory answer to the Party and the people.
original title: Xin Bazaar to create a "three-in-one" new regulatory model to comprehensively improve the long-term governance effectiveness of health insurance funds.