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Medical Network News on March 25th.
The major provinces of medicine released the latest documents to strengthen the control of medical insurance; from May 1st, the country will strengthen the supervision of the use of medical expenses
The major provinces of medicine released the latest documents to strengthen the control of medical insurance; from May 1st, the country will strengthen the supervision of the use of medical expenses
Hebei Medical Insurance Bureau: Strengthening the supervision and inspection of medical expenses
On March 23, the Hebei Medical Insurance Bureau issued the "Implementation Opinions on Establishing a Normalized, Institutionalized, and Refined Supervision Mechanism for Designated Medical Institutions", which clarified that the supervision and inspection of medical expenses will be strengthened.
The opinion pointed out that the medical insurance administrative department should strengthen the supervision and inspection of the medical service activities and medical expenses of the designated medical institutions included in the medical insurance fund payment scope, mainly including: medical insurance management issues of designated medical institutions, general violations of laws and regulations, and fraudulent insurance issues.
Specifically, whether the hospital has excessive diagnosis and treatment, whether it implements the medical insurance catalogue, whether it is inclined to purchase high-priced drugs and consumables, whether it implements the centralized procurement policy of drugs and consumables, etc.
, are all within the scope of supervision and inspection.
, are all within the scope of supervision and inspection.
In particular, the following inspection items are closely related to the gray operations of pharmaceutical companies in the hospital drug procurement and in-hospital drug use links.
It can be said that the drug companies cannibalize medical insurance funds through non-compliant market means.
It can be said that the drug companies cannibalize medical insurance funds through non-compliant market means.
Overdiagnosis and treatment
The compliance of medical insurance expenses declared by designated medical institutions, whether there are excessive diagnosis and treatment, over-standard charges, cross-charging, provision of other unnecessary medical services, or declaration of expenses that are not covered by the medical insurance fund for settlement of medical insurance funds, etc.
Preference for high-priced drugs
The procurement and use of drugs and medical consumables by designated medical institutions, whether there are abnormal purchases of high-priced drugs, low-priced drugs, high-priced consumables, and low-priced consumables; whether there are large-volume procurement of drugs and the use of national talks Abnormal situations such as less use of replaceable drugs; whether there are abnormal situations such as less use of purchased consumables and more use of replaceable consumables; problems such as excessively high prices of medical insurance settlement drugs in designated retail pharmacies.
Implement quantity procurement
Designated medical institutions if the implementation of medicines, supplies centralized procurement policy with the amount, whether the implementation of medicines, supplies, payment policies, timely to drugs or supplies production enterprises disbursement of funds; whether the balance of the retained funds to implement the regulations governing the use, as specified proportion of salaries for medical staff Issuance, etc.
The industry has been paying attention to the problem that some medical institutions tend to purchase high-priced drugs and consumables.
Some Cyberlan readers have pointed out that due to this tendency, many low-cost drugs and commonly used drugs have no choice but to withdraw from the provincial recruitment platform.
There is even a shortage.
Some Cyberlan readers have pointed out that due to this tendency, many low-cost drugs and commonly used drugs have no choice but to withdraw from the provincial recruitment platform.
There is even a shortage.
According to Cyber Blue, as early as 2020, the Hebei Medical Insurance Bureau issued multiple notices pointing to the abnormal cost increase of the hospital .
On April 23, 2020, the Hebei Medical Insurance Bureau issued the "Notice on Establishing an Early Warning System for the Abnormal Growth of Medical Expenses in Designated Medical Institutions".
Indicators are monitored in real time.
Related indicators include whether total medical expenses exceed 150% year-on-year or month-on-month.
Indicators are monitored in real time.
Related indicators include whether total medical expenses exceed 150% year-on-year or month-on-month.
The notice is clear: large prescriptions and excessive inspections are strictly prohibited
The notice pointed out that the inspections and audits of medical insurance agencies will be carried out on a regular basis, which are mainly divided into three forms: daily audits, special inspections, and key inspections.
Key inspections will be conducted based on the risk assessment of the medical security fund, reporting and complaint clues, medical security data monitoring, and emergencies and outstanding issues in the operation of medical security.
Such as the high prices of medicines and medical consumables.
Such as the high prices of medicines and medical consumables.
In addition, the medical insurance agency will also realize the normalization of unannounced inspections at the same time-full coverage of random inspections based on administrative inspections.
An unannounced inspection plan is formulated every year.
In principle, the scope of the provincial spot check is focused on the top 30 designated medical institutions in each coordinating area’s fund payment in the previous year, combined with complaints and reports, etc.
, and the proportion of spot checks is not less than 10%, realizing the full scope of spot checks in each coordinating area cover.
In principle, the scope of the provincial spot check is focused on the top 30 designated medical institutions in each coordinating area’s fund payment in the previous year, combined with complaints and reports, etc.
, and the proportion of spot checks is not less than 10%, realizing the full scope of spot checks in each coordinating area cover.
In addition to regular medical insurance inspections, relevant departments will also promote:
Indicator early warning: Regular and irregular reminders-push notifications for abnormal indicators such as "the same generic drug only purchases high prices but not low purchase prices", "drugs and medical consumables have a high settlement price", and "average cost per second exceeds the standard".
For medical institutions that still have abnormal increases in medical expenses for two consecutive times, the appointment reminder mechanism will be activated, and for medical institutions whose relevant expenses indicators have continued to increase abnormally after the interview, the listing supervision procedure will be initiated.
For medical institutions that still have abnormal increases in medical expenses for two consecutive times, the appointment reminder mechanism will be activated, and for medical institutions whose relevant expenses indicators have continued to increase abnormally after the interview, the listing supervision procedure will be initiated.
Normalized self-inspection and self-inspection of designated medical institutions-designated medical institutions strictly implement the responsibilities specified in the agreement management, strengthen the management of internal departments and medical insurance physicians, and conduct in-depth investigation of risks.
The investigation must include full coverage of the departments and medical staff, and prevent bedridden hospitalization.
False diagnosis and treatment, false inspection, false price, collusion of items and other non-compliant diagnosis and treatment behaviors, strictly prevent the occurrence of excessive diagnosis and treatment and excessive inspection, and strictly prohibit medical institutions and medical staff from issuing "big prescriptions" and inducing patients to purchase drugs out of hospitals.
The investigation should be established.
Account and make a commitment.
The investigation must include full coverage of the departments and medical staff, and prevent bedridden hospitalization.
False diagnosis and treatment, false inspection, false price, collusion of items and other non-compliant diagnosis and treatment behaviors, strictly prevent the occurrence of excessive diagnosis and treatment and excessive inspection, and strictly prohibit medical institutions and medical staff from issuing "big prescriptions" and inducing patients to purchase drugs out of hospitals.
The investigation should be established.
Account and make a commitment.
Make full use of the big data analysis system to gradually realize the automatic discovery, automatic reminder, and automatic intervention of unreasonable medical behaviors.
Institutional measures: priority use of medical insurance drugs and essential drugs
In order to promote the institutionalization of supervision and inspection, the notice clearly stated:
Establish an early warning and reminder mechanism-according to the local reality and the risk level of designated medical institutions, for the rapid growth of medical expenses, high average cost, high proportion of patients' self-finance, high proportion of inspection costs, more use of items outside the catalog, and low prices for purchasing high-priced drugs For abnormal conditions such as fewer drugs and short hospitalization intervals, conduct monitoring and analysis, establish an early warning and reminder mechanism, and make appropriate disclosures so that medical institutions can take the initiative to regulate.
Standardize the interactive process of doubtful points—strengthen the effect of agreement clauses and indicator constraints, and include priority use of medical insurance catalog drugs (medical consumables), control of the proportion of self-pay, prohibition of inducing drugs to be purchased out of hospitals, and issuing large prescriptions in violation of regulations, etc.
, into the management of the agreement.
Standardize monitoring rules implantation, formation and push of doubtful points, doubtful point feedback and preliminary review, doubtful point review, deduction approval and other doubtful question interaction processes, and further improve the management of periodic push of doubtful points, timely feedback from medical institutions, reminders of key issues, and rectification and deductions.
system.
, into the management of the agreement.
Standardize monitoring rules implantation, formation and push of doubtful points, doubtful point feedback and preliminary review, doubtful point review, deduction approval and other doubtful question interaction processes, and further improve the management of periodic push of doubtful points, timely feedback from medical institutions, reminders of key issues, and rectification and deductions.
system.
Institutionalization of assessment management—According to the assessment methods of designated medical institutions, designated retail pharmacies, and medical insurance physicians, the utilization rate indicators in the medical insurance catalog of medical institutions are included in the daily supervision and evaluation of medical insurance agreements, and the primary, secondary, and tertiary public designated medical institutions are required to use basic Drugs should reach 90%, 80%, and 60% respectively.
The annual assessment results are linked to the year-end settlement of medical insurance costs, the return of quality guarantee funds, the credit rating and management of designated medical institutions, the renewal and termination of agreements, etc.
, to encourage medical institutions to strengthen themselves Management, play the role of incentive and restraint of medical insurance.
The annual assessment results are linked to the year-end settlement of medical insurance costs, the return of quality guarantee funds, the credit rating and management of designated medical institutions, the renewal and termination of agreements, etc.
, to encourage medical institutions to strengthen themselves Management, play the role of incentive and restraint of medical insurance.
Further increase medical insurance control fees nationwide
It is worth noting that the notice issued by Hebei Medical Insurance Bureau pointed out that the supervision process will be refined.
Promote the shift from a single “money management” to “service management, technology management, and price management”.
The target of supervision is extended from medical institutions to medical personnel, and the focus of supervision is shifted from medical expense control to dual control of medical expenses and medical service performance.
Promote the shift from a single “money management” to “service management, technology management, and price management”.
The target of supervision is extended from medical institutions to medical personnel, and the focus of supervision is shifted from medical expense control to dual control of medical expenses and medical service performance.
In response to the characteristics of fraudulent insurance fraud , the basic information standard database such as medicines , diagnosis and treatment items and medical service facilities has been continuously improved , and the intelligent monitoring rules shall be updated and improved in time in conjunction with the adjustment of medical insurance benefits and payment policies to improve the efficiency of intelligent monitoring.
For doubts and violations, one hospital, one doctor, and one medical record should be checked, accurate to the purchase, sales and inventory of medicines and medical consumables, and accurate to the scope of use of diagnosis and treatment items, forming a powerful deterrent against fraudulent insurance .
At the same time, it will also realize the refined analysis of results-administrative supervision and handling agencies should regularly and irregularly summarize the supervision and inspection situation, and analyze the total cost, average cost, drug cost, medical consumable cost, and cost from different aspects, angles, and dimensions.
The situation of the people visiting the clinic, dig deep into the root of the problems, and provide references for formulating and improving policies on medical prices, medical insurance payments, and medical insurance benefits.
The situation of the people visiting the clinic, dig deep into the root of the problems, and provide references for formulating and improving policies on medical prices, medical insurance payments, and medical insurance benefits.
In fact, with the formal implementation of the medical insurance fund supervision regulations, it is expected that a round of normalized medical cost control may be set off across the country.
A few days ago, the "Regulations on the Supervision and Administration of the Use of Medical Security Funds" were adopted at the 117th executive meeting of the State Council on December 9, 2020 and officially announced.
On May 1 this year, the "Regulations on the Supervision and Administration of the Use of Medical Security Funds" were formally implemented.
Article 15 of the Regulations stipulates-Designated medical institutions and their staff shall provide reasonable and necessary medical services in accordance with the diagnosis and treatment specifications, and truthfully issue expense receipts and related materials to the insured persons, shall not disassemble the hospitalization, stay in bed, and shall not violate the diagnosis and treatment Regulate over-diagnosis and treatment, over-examination, decomposition of prescriptions, over-prescribing, and re-prescribing of medicines, no repeated charges, over-standard charges, disaggregated item charges, no exchange of medicines, medical consumables, diagnosis and treatment items and service facilities, and no inducement or assistance to others Or fake medical treatment or drug purchase.
It is expected that in addition to Hebei, more provinces and cities across the country will follow the pace of the medical insurance fund supervision regulations, strengthen the supervision of the use of medical insurance funds, and increase the control of unreasonable use of medical expenses.
Medical Network News on March 25th.
The major provinces of medicine released the latest documents to strengthen the control of medical insurance; from May 1st, the country will strengthen the supervision of the use of medical expenses
The major provinces of medicine released the latest documents to strengthen the control of medical insurance; from May 1st, the country will strengthen the supervision of the use of medical expenses
Hebei Medical Insurance Bureau: Strengthening the supervision and inspection of medical expenses
On March 23, the Hebei Medical Insurance Bureau issued the "Implementation Opinions on Establishing a Normalized, Institutionalized, and Refined Supervision Mechanism for Designated Medical Institutions", which clarified that the supervision and inspection of medical expenses will be strengthened.
The opinion pointed out that the medical insurance administrative department should strengthen the supervision and inspection of the medical service activities and medical expenses of the designated medical institutions included in the medical insurance fund payment scope, mainly including: medical insurance management issues of designated medical institutions, general violations of laws and regulations, and fraudulent insurance issues.
Specifically, whether the hospital has excessive diagnosis and treatment, whether it implements the medical insurance catalogue, whether it is inclined to purchase high-priced drugs and consumables, whether it implements the centralized procurement policy of drugs and consumables, etc.
, are all within the scope of supervision and inspection.
, are all within the scope of supervision and inspection.
In particular, the following inspection items are closely related to the gray operations of pharmaceutical companies in the hospital drug procurement and in-hospital drug use links.
It can be said that the drug companies cannibalize medical insurance funds through non-compliant market means.
It can be said that the drug companies cannibalize medical insurance funds through non-compliant market means.
Overdiagnosis and treatment
The compliance of medical insurance expenses declared by designated medical institutions, whether there are excessive diagnosis and treatment, over-standard charges, cross-charging, provision of other unnecessary medical services, or declaration of expenses that are not covered by the medical insurance fund for settlement of medical insurance funds, etc.
Preference for high-priced drugs
The procurement and use of drugs and medical consumables by designated medical institutions, whether there are abnormal purchases of high-priced drugs, low-priced drugs, high-priced consumables, and low-priced consumables; whether there are large-volume procurement of drugs and the use of national talks Abnormal situations such as less use of replaceable drugs; whether there are abnormal situations such as less use of purchased consumables and more use of replaceable consumables; problems such as excessively high prices of medical insurance settlement drugs in designated retail pharmacies.
Implement quantity procurement
Designated medical institutions if the implementation of medicines, supplies centralized procurement policy with the amount, whether the implementation of medicines, supplies, payment policies, timely to drugs or supplies production enterprises disbursement of funds; whether the balance of the retained funds to implement the regulations governing the use, as specified proportion of salaries for medical staff Issuance, etc.
The industry has been paying attention to the problem that some medical institutions tend to purchase high-priced drugs and consumables.
Some Cyberlan readers have pointed out that due to this tendency, many low-cost drugs and commonly used drugs have no choice but to withdraw from the provincial recruitment platform.
There is even a shortage.
Some Cyberlan readers have pointed out that due to this tendency, many low-cost drugs and commonly used drugs have no choice but to withdraw from the provincial recruitment platform.
There is even a shortage.
According to Cyber Blue, as early as 2020, the Hebei Medical Insurance Bureau issued multiple notices pointing to the abnormal cost increase of the hospital .
On April 23, 2020, the Hebei Medical Insurance Bureau issued the "Notice on Establishing an Early Warning System for the Abnormal Growth of Medical Expenses in Designated Medical Institutions".
Indicators are monitored in real time.
Related indicators include whether total medical expenses exceed 150% year-on-year or month-on-month.
Indicators are monitored in real time.
Related indicators include whether total medical expenses exceed 150% year-on-year or month-on-month.
The notice is clear: large prescriptions and excessive inspections are strictly prohibited
The notice pointed out that the inspections and audits of medical insurance agencies will be carried out on a regular basis, which are mainly divided into three forms: daily audits, special inspections, and key inspections.
Key inspections will be conducted based on the risk assessment of the medical security fund, reporting and complaint clues, medical security data monitoring, and emergencies and outstanding issues in the operation of medical security.
Such as the high prices of medicines and medical consumables.
Such as the high prices of medicines and medical consumables.
In addition, the medical insurance agency will also realize the normalization of unannounced inspections at the same time-full coverage of random inspections based on administrative inspections.
An unannounced inspection plan is formulated every year.
In principle, the scope of the provincial spot check is focused on the top 30 designated medical institutions in each coordinating area’s fund payment in the previous year, combined with complaints and reports, etc.
, and the proportion of spot checks is not less than 10%, realizing the full scope of spot checks in each coordinating area cover.
In principle, the scope of the provincial spot check is focused on the top 30 designated medical institutions in each coordinating area’s fund payment in the previous year, combined with complaints and reports, etc.
, and the proportion of spot checks is not less than 10%, realizing the full scope of spot checks in each coordinating area cover.
In addition to regular medical insurance inspections, relevant departments will also promote:
Indicator early warning: Regular and irregular reminders-push notifications for abnormal indicators such as "the same generic drug only purchases high prices but not low purchase prices", "drugs and medical consumables have a high settlement price", and "average cost per second exceeds the standard".
For medical institutions that still have abnormal increases in medical expenses for two consecutive times, the appointment reminder mechanism will be activated, and for medical institutions whose relevant expenses indicators have continued to increase abnormally after the interview, the listing supervision procedure will be initiated.
For medical institutions that still have abnormal increases in medical expenses for two consecutive times, the appointment reminder mechanism will be activated, and for medical institutions whose relevant expenses indicators have continued to increase abnormally after the interview, the listing supervision procedure will be initiated.
Normalized self-inspection and self-inspection of designated medical institutions-designated medical institutions strictly implement the responsibilities specified in the agreement management, strengthen the management of internal departments and medical insurance physicians, and conduct in-depth investigation of risks.
The investigation must include full coverage of the departments and medical staff, and prevent bedridden hospitalization.
False diagnosis and treatment, false inspection, false price, collusion of items and other non-compliant diagnosis and treatment behaviors, strictly prevent the occurrence of excessive diagnosis and treatment and excessive inspection, and strictly prohibit medical institutions and medical staff from issuing "big prescriptions" and inducing patients to purchase drugs out of hospitals.
The investigation should be established.
Account and make a commitment.
The investigation must include full coverage of the departments and medical staff, and prevent bedridden hospitalization.
False diagnosis and treatment, false inspection, false price, collusion of items and other non-compliant diagnosis and treatment behaviors, strictly prevent the occurrence of excessive diagnosis and treatment and excessive inspection, and strictly prohibit medical institutions and medical staff from issuing "big prescriptions" and inducing patients to purchase drugs out of hospitals.
The investigation should be established.
Account and make a commitment.
Make full use of the big data analysis system to gradually realize the automatic discovery, automatic reminder, and automatic intervention of unreasonable medical behaviors.
Institutional measures: priority use of medical insurance drugs and essential drugs
In order to promote the institutionalization of supervision and inspection, the notice clearly stated:
Establish an early warning and reminder mechanism-according to the local reality and the risk level of designated medical institutions, for the rapid growth of medical expenses, high average cost, high proportion of patients' self-finance, high proportion of inspection costs, more use of items outside the catalog, and low prices for purchasing high-priced drugs For abnormal conditions such as fewer drugs and short hospitalization intervals, conduct monitoring and analysis, establish an early warning and reminder mechanism, and make appropriate disclosures so that medical institutions can take the initiative to regulate.
Standardize the interactive process of doubtful points—strengthen the effect of agreement clauses and indicator constraints, and include priority use of medical insurance catalog drugs (medical consumables), control of the proportion of self-pay, prohibition of inducing drugs to be purchased out of hospitals, and issuing large prescriptions in violation of regulations, etc.
, into the management of the agreement.
Standardize monitoring rules implantation, formation and push of doubtful points, doubtful point feedback and preliminary review, doubtful point review, deduction approval and other doubtful question interaction processes, and further improve the management of periodic push of doubtful points, timely feedback from medical institutions, reminders of key issues, and rectification and deductions.
system.
, into the management of the agreement.
Standardize monitoring rules implantation, formation and push of doubtful points, doubtful point feedback and preliminary review, doubtful point review, deduction approval and other doubtful question interaction processes, and further improve the management of periodic push of doubtful points, timely feedback from medical institutions, reminders of key issues, and rectification and deductions.
system.
Institutionalization of assessment management—According to the assessment methods of designated medical institutions, designated retail pharmacies, and medical insurance physicians, the utilization rate indicators in the medical insurance catalog of medical institutions are included in the daily supervision and evaluation of medical insurance agreements, and the primary, secondary, and tertiary public designated medical institutions are required to use basic Drugs should reach 90%, 80%, and 60% respectively.
The annual assessment results are linked to the year-end settlement of medical insurance costs, the return of quality guarantee funds, the credit rating and management of designated medical institutions, the renewal and termination of agreements, etc.
, to encourage medical institutions to strengthen themselves Management, play the role of incentive and restraint of medical insurance.
The annual assessment results are linked to the year-end settlement of medical insurance costs, the return of quality guarantee funds, the credit rating and management of designated medical institutions, the renewal and termination of agreements, etc.
, to encourage medical institutions to strengthen themselves Management, play the role of incentive and restraint of medical insurance.
Further increase medical insurance control fees nationwide
It is worth noting that the notice issued by Hebei Medical Insurance Bureau pointed out that the supervision process will be refined.
Promote the shift from a single “money management” to “service management, technology management, and price management”.
The target of supervision is extended from medical institutions to medical personnel, and the focus of supervision is shifted from medical expense control to dual control of medical expenses and medical service performance.
Promote the shift from a single “money management” to “service management, technology management, and price management”.
The target of supervision is extended from medical institutions to medical personnel, and the focus of supervision is shifted from medical expense control to dual control of medical expenses and medical service performance.
In response to the characteristics of fraudulent insurance fraud , the basic information standard database such as medicines , diagnosis and treatment items and medical service facilities has been continuously improved , and the intelligent monitoring rules shall be updated and improved in time in conjunction with the adjustment of medical insurance benefits and payment policies to improve the efficiency of intelligent monitoring.
For doubts and violations, one hospital, one doctor, and one medical record should be checked, accurate to the purchase, sales and inventory of medicines and medical consumables, and accurate to the scope of use of diagnosis and treatment items, forming a powerful deterrent against fraudulent insurance .
At the same time, it will also realize the refined analysis of results-administrative supervision and handling agencies should regularly and irregularly summarize the supervision and inspection situation, and analyze the total cost, average cost, drug cost, medical consumable cost, and cost from different aspects, angles, and dimensions.
The situation of the people visiting the clinic, dig deep into the root of the problems, and provide references for formulating and improving policies on medical prices, medical insurance payments, and medical insurance benefits.
The situation of the people visiting the clinic, dig deep into the root of the problems, and provide references for formulating and improving policies on medical prices, medical insurance payments, and medical insurance benefits.
In fact, with the formal implementation of the medical insurance fund supervision regulations, it is expected that a round of normalized medical cost control may be set off across the country.
A few days ago, the "Regulations on the Supervision and Administration of the Use of Medical Security Funds" were adopted at the 117th executive meeting of the State Council on December 9, 2020 and officially announced.
On May 1 this year, the "Regulations on the Supervision and Administration of the Use of Medical Security Funds" were formally implemented.
Article 15 of the Regulations stipulates-Designated medical institutions and their staff shall provide reasonable and necessary medical services in accordance with the diagnosis and treatment specifications, and truthfully issue expense receipts and related materials to the insured persons, shall not disassemble the hospitalization, stay in bed, and shall not violate the diagnosis and treatment Regulate over-diagnosis and treatment, over-examination, decomposition of prescriptions, over-prescribing, and re-prescribing of medicines, no repeated charges, over-standard charges, disaggregated item charges, no exchange of medicines, medical consumables, diagnosis and treatment items and service facilities, and no inducement or assistance to others Or fake medical treatment or drug purchase.
It is expected that in addition to Hebei, more provinces and cities across the country will follow the pace of the medical insurance fund supervision regulations, strengthen the supervision of the use of medical insurance funds, and increase the control of unreasonable use of medical expenses.
Medical Network News on March 25th.
The major provinces of medicine released the latest documents to strengthen the control of medical insurance; from May 1st, the country will strengthen the supervision of the use of medical expenses
The major provinces of medicine released the latest documents to strengthen the control of medical insurance; from May 1st, the country will strengthen the supervision of the use of medical expenses
Hebei Medical Insurance Bureau: Strengthening the supervision and inspection of medical expenses
Hebei Medical Insurance Bureau: Strengthening the supervision and inspection of medical expenses On March 23, the Hebei Medical Insurance Bureau issued the "Implementation Opinions on Establishing a Normalized, Institutionalized, and Refined Supervision Mechanism for Designated Medical Institutions", which clarified that the supervision and inspection of medical expenses will be strengthened.
The opinion pointed out that the medical insurance administrative department should strengthen the supervision and inspection of the medical service activities and medical expenses of the designated medical institutions included in the medical insurance fund payment scope, mainly including: medical insurance management issues of designated medical institutions, general violations of laws and regulations, and fraudulent insurance issues.
Specifically, whether the hospital has excessive diagnosis and treatment, whether it implements the medical insurance catalogue, whether it is inclined to purchase high-priced drugs and consumables, whether it implements the centralized procurement policy of drugs and consumables, etc.
, are all within the scope of supervision and inspection.
, are all within the scope of supervision and inspection.
In particular, the following inspection items are closely related to the gray operations of pharmaceutical companies in the hospital drug procurement and in-hospital drug use links.
It can be said that the drug companies cannibalize medical insurance funds through non-compliant market means.
It can be said that the drug companies cannibalize medical insurance funds through non-compliant market means.
Overdiagnosis and treatment
Overdiagnosis and treatment The compliance of medical insurance expenses declared by designated medical institutions, whether there are excessive diagnosis and treatment, over-standard charges, cross-charging, provision of other unnecessary medical services, or declaration of expenses that are not covered by the medical insurance fund for settlement of medical insurance funds, etc.
Preference for high-priced drugs
Preference for high-priced drugs The procurement and use of drugs and medical consumables by designated medical institutions, whether there are abnormal purchases of high-priced drugs, low-priced drugs, high-priced consumables, and low-priced consumables; whether there are large-volume procurement of drugs and the use of national talks Abnormal situations such as less use of replaceable drugs; whether there are abnormal situations such as less use of purchased consumables and more use of replaceable consumables; problems such as excessively high prices of medical insurance settlement drugs in designated retail pharmacies.
Implement quantity procurement
Implement quantity procurement Designated medical institutions if the implementation of medicines, supplies centralized procurement policy with the amount, whether the implementation of medicines, supplies, payment policies, timely to drugs or supplies production enterprises disbursement of funds; whether the balance of the retained funds to implement the regulations governing the use, as specified proportion of salaries for medical staff Issuance, etc.
Enterprise business enterprise The industry has been paying attention to the problem that some medical institutions tend to purchase high-priced drugs and consumables.
Some Cyberlan readers have pointed out that due to this tendency, many low-cost drugs and commonly used drugs have no choice but to withdraw from the provincial recruitment platform.
There is even a shortage.
Some Cyberlan readers have pointed out that due to this tendency, many low-cost drugs and commonly used drugs have no choice but to withdraw from the provincial recruitment platform.
There is even a shortage.
According to Cyber Blue, as early as 2020, the Hebei Medical Insurance Bureau issued multiple notices pointing to the abnormal cost increase of the hospital .
Hospital hospital hospital On April 23, 2020, the Hebei Medical Insurance Bureau issued the "Notice on Establishing an Early Warning System for the Abnormal Growth of Medical Expenses in Designated Medical Institutions".
Indicators are monitored in real time.
Related indicators include whether total medical expenses exceed 150% year-on-year or month-on-month.
Indicators are monitored in real time.
Related indicators include whether total medical expenses exceed 150% year-on-year or month-on-month.
The notice is clear: large prescriptions and excessive inspections are strictly prohibited
The notice is clear: large prescriptions and excessive inspections are strictly prohibited The notice pointed out that the inspections and audits of medical insurance agencies will be carried out on a regular basis, which are mainly divided into three forms: daily audits, special inspections, and key inspections.
Key inspections will be conducted based on the risk assessment of the medical security fund, reporting and complaint clues, medical security data monitoring, and emergencies and outstanding issues in the operation of medical security.
Such as the high prices of medicines and medical consumables.
Such as the high prices of medicines and medical consumables.
In addition, the medical insurance agency will also realize the normalization of unannounced inspections at the same time-full coverage of random inspections based on administrative inspections.
An unannounced inspection plan is formulated every year.
In principle, the scope of the provincial spot check is focused on the top 30 designated medical institutions in each coordinating area’s fund payment in the previous year, combined with complaints and reports, etc.
, and the proportion of spot checks is not less than 10%, realizing the full scope of spot checks in each coordinating area cover.
In principle, the scope of the provincial spot check is focused on the top 30 designated medical institutions in each coordinating area’s fund payment in the previous year, combined with complaints and reports, etc.
, and the proportion of spot checks is not less than 10%, realizing the full scope of spot checks in each coordinating area cover.
In addition to regular medical insurance inspections, relevant departments will also promote:
Indicator early warning: Regular and irregular reminders-push notifications for abnormal indicators such as "the same generic drug only purchases high prices but not low purchase prices", "drugs and medical consumables have a high settlement price", and "average cost per second exceeds the standard".
For medical institutions that still have abnormal increases in medical expenses for two consecutive times, the appointment reminder mechanism will be activated, and for medical institutions whose relevant expenses indicators have continued to increase abnormally after the interview, the listing supervision procedure will be initiated.
For medical institutions that still have abnormal increases in medical expenses for two consecutive times, the appointment reminder mechanism will be activated, and for medical institutions whose relevant expenses indicators have continued to increase abnormally after the interview, the listing supervision procedure will be initiated.
Normalized self-inspection and self-inspection of designated medical institutions-designated medical institutions strictly implement the responsibilities specified in the agreement management, strengthen the management of internal departments and medical insurance physicians, and conduct in-depth investigation of risks.
The investigation must include full coverage of the departments and medical staff, and prevent bedridden hospitalization.
False diagnosis and treatment, false inspection, false price, collusion of items and other non-compliant diagnosis and treatment behaviors, strictly prevent the occurrence of excessive diagnosis and treatment and excessive inspection, and strictly prohibit medical institutions and medical staff from issuing "big prescriptions" and inducing patients to purchase drugs out of hospitals.
The investigation should be established.
Account and make a commitment.
The investigation must include full coverage of the departments and medical staff, and prevent bedridden hospitalization.
False diagnosis and treatment, false inspection, false price, collusion of items and other non-compliant diagnosis and treatment behaviors, strictly prevent the occurrence of excessive diagnosis and treatment and excessive inspection, and strictly prohibit medical institutions and medical staff from issuing "big prescriptions" and inducing patients to purchase drugs out of hospitals.
The investigation should be established.
Account and make a commitment.
Make full use of the big data analysis system to gradually realize the automatic discovery, automatic reminder, and automatic intervention of unreasonable medical behaviors.
Institutional measures: priority use of medical insurance drugs and essential drugs
Institutional measures: priority use of medical insurance drugs and essential drugs In order to promote the institutionalization of supervision and inspection, the notice clearly stated:
Establish an early warning and reminder mechanism-according to the local reality and the risk level of designated medical institutions, for the rapid growth of medical expenses, high average cost, high proportion of patients' self-finance, high proportion of inspection costs, more use of items outside the catalog, and low prices for purchasing high-priced drugs For abnormal conditions such as fewer drugs and short hospitalization intervals, conduct monitoring and analysis, establish an early warning and reminder mechanism, and make appropriate disclosures so that medical institutions can take the initiative to regulate.
Standardize the interactive process of doubtful points—strengthen the effect of agreement clauses and indicator constraints, and include priority use of medical insurance catalog drugs (medical consumables), control of the proportion of self-pay, prohibition of inducing drugs to be purchased out of hospitals, and issuing large prescriptions in violation of regulations, etc.
, into the management of the agreement.
Standardize monitoring rules implantation, formation and push of doubtful points, doubtful point feedback and preliminary review, doubtful point review, deduction approval and other doubtful question interaction processes, and further improve the management of periodic push of doubtful points, timely feedback from medical institutions, reminders of key issues, and rectification and deductions.
system.
, into the management of the agreement.
Standardize monitoring rules implantation, formation and push of doubtful points, doubtful point feedback and preliminary review, doubtful point review, deduction approval and other doubtful question interaction processes, and further improve the management of periodic push of doubtful points, timely feedback from medical institutions, reminders of key issues, and rectification and deductions.
system.
Institutionalization of assessment management—According to the assessment methods of designated medical institutions, designated retail pharmacies, and medical insurance physicians, the utilization rate indicators in the medical insurance catalog of medical institutions are included in the daily supervision and evaluation of medical insurance agreements, and the primary, secondary, and tertiary public designated medical institutions are required to use basic Drugs should reach 90%, 80%, and 60% respectively.
The annual assessment results are linked to the year-end settlement of medical insurance costs, the return of quality guarantee funds, the credit rating and management of designated medical institutions, the renewal and termination of agreements, etc.
, to encourage medical institutions to strengthen themselves Management, play the role of incentive and restraint of medical insurance.
Pharmacy pharmacy pharmacyThe annual assessment results are linked to the year-end settlement of medical insurance costs, the return of quality guarantee funds, the credit rating and management of designated medical institutions, the renewal and termination of agreements, etc.
, to encourage medical institutions to strengthen themselves Management, play the role of incentive and restraint of medical insurance.
Further increase medical insurance control fees nationwide
Further increase medical insurance control fees nationwide It is worth noting that the notice issued by Hebei Medical Insurance Bureau pointed out that the supervision process will be refined.
Promote the shift from a single “money management” to “service management, technology management, and price management”.
The target of supervision is extended from medical institutions to medical personnel, and the focus of supervision is shifted from medical expense control to dual control of medical expenses and medical service performance.
Promote the shift from a single “money management” to “service management, technology management, and price management”.
The target of supervision is extended from medical institutions to medical personnel, and the focus of supervision is shifted from medical expense control to dual control of medical expenses and medical service performance.
In response to the characteristics of fraudulent insurance fraud , the basic information standard database such as medicines , diagnosis and treatment items and medical service facilities has been continuously improved , and the intelligent monitoring rules shall be updated and improved in time in conjunction with the adjustment of medical insurance benefits and payment policies to improve the efficiency of intelligent monitoring.
Medicine, medicine, medicine For doubts and violations, one hospital, one doctor, and one medical record should be checked, accurate to the purchase, sales and inventory of medicines and medical consumables, and accurate to the scope of use of diagnosis and treatment items, forming a powerful deterrent against fraudulent insurance .
At the same time, it will also realize the refined analysis of results-administrative supervision and handling agencies should regularly and irregularly summarize the supervision and inspection situation, and analyze the total cost, average cost, drug cost, medical consumable cost, and cost from different aspects, angles, and dimensions.
The situation of the people visiting the clinic, dig deep into the root of the problems, and provide references for formulating and improving policies on medical prices, medical insurance payments, and medical insurance benefits.
Medicine Medicine MedicineThe situation of the people visiting the clinic, dig deep into the root of the problems, and provide references for formulating and improving policies on medical prices, medical insurance payments, and medical insurance benefits.
In fact, with the formal implementation of the medical insurance fund supervision regulations, it is expected that a round of normalized medical cost control may be set off across the country.
A few days ago, the "Regulations on the Supervision and Administration of the Use of Medical Security Funds" were adopted at the 117th executive meeting of the State Council on December 9, 2020 and officially announced.
On May 1 this year, the "Regulations on the Supervision and Administration of the Use of Medical Security Funds" were formally implemented.
Article 15 of the Regulations stipulates-Designated medical institutions and their staff shall provide reasonable and necessary medical services in accordance with the diagnosis and treatment specifications, and truthfully issue expense receipts and related materials to the insured persons, shall not disassemble the hospitalization, stay in bed, and shall not violate the diagnosis and treatment Regulate over-diagnosis and treatment, over-examination, decomposition of prescriptions, over-prescribing, and re-prescribing of medicines, no repeated charges, over-standard charges, disaggregated item charges, no exchange of medicines, medical consumables, diagnosis and treatment items and service facilities, and no inducement or assistance to others Or fake medical treatment or drug purchase.
It is expected that in addition to Hebei, more provinces and cities across the country will follow the pace of the medical insurance fund supervision regulations, strengthen the supervision of the use of medical insurance funds, and increase the control of unreasonable use of medical expenses.
