Interim Measures for the Fixed-Point Management of Medical Security in Medical Institutions

Medicine Network January 13th, nearly a year after the draft was issued for comments, the interim approach to the management of medical security in medical institutions has finally come! Recently, according to the official information of the State Administration of Medical Security, the Interim Measures for the Administration of Medical Security In Medical Care in Medical Institutions have been considered and adopted at the 2nd Bureau Meeting on December 24, 2020 and will come into effect on February 1, 2021.
According to the Medical Watch Community, in February 2020, the State Administration of Medical Security drafted the Interim Measures for the Administration of Medical Security Fixed-point (Draft for Comments), and this formal management method has made a relatively large adjustment on the basis of the draft for comments, and all medical insurance fixed-point medical institutions have made good research and study, understood the new regulations on medical insurance management, and operated in accordance with the law.
chapter I General Rules of the Interim Measures for the Administration of Medical Security in Medical Institutions Chapter 1 These Measures are formulated in accordance with the Social Insurance Law of the People's Republic of China, the Basic Medical and Health Promotion Law of the People's Republic of China and the Regulations on the Administration of Medical Institutions, in order to strengthen and standardize the fixed-point management of medical security in medical institutions, improve the efficiency of the use of medical security funds, and better protect the rights and interests of the vast number of insured persons.
Article 2 The fixed-point management of medical security in medical institutions shall adhere to the principle of ensuring basic, fair and just, clear and dynamic balance of rights and responsibilities, strengthen the fine management of medical insurance, promote the reform of the supply side of medical institutions, and provide appropriate medical services to the insured personnel.
article 3 The administrative department of medical security shall be responsible for formulating the policy of fixed-point management of medical institutions, and shall supervise the medical security agencies (hereinafter referred to as "operation agencies") and fixed-point medical institutions in the areas of fixed-point application, professional evaluation, negotiation and negotiation, agreement formation, agreement implementation and agreement lifting.
are responsible for identifying designated medical institutions and signing medical security service agreements (hereinafter referred to as "medical insurance agreements") with designated medical institutions, providing management services, and carrying out medical insurance agreement management and assessment.
medical institutions shall abide by the laws, regulations, regulations and relevant policies on medical security and provide medical services to the insured persons in accordance with the provisions.
chapter II Identification of fixed-point medical institutions Article 4 The administrative department of medical security in an integrated area shall determine the allocation of resources for fixed-point medical services in the region in accordance with public health needs, management service needs, income and expenditure of the medical insurance fund, regional health planning, medical institution establishment planning, etc. article
Medical institutions that have obtained a medical institution's license to practise or a Chinese medicine clinic's record certificate below, as well as military medical institutions with qualifications for serving the people approved by the competent military departments, may apply for medical insurance fixed-point: (1) general hospitals, Chinese and Western medicine combined hospitals, ethnic medicine hospitals, specialized hospitals, rehabilitation hospitals; Hospitals; (3) community health service centers (stations), central health hospitals, township hospitals, street health hospitals, outpatient clinics, clinics, health clinics (stations), village health rooms (houses) ;(4) independently set up emergency centers; (5) peaceful treatment centers, hemodialysis centers, nursing homes; and (6) medical institutions in old-age institutions.
Internet hospital may apply for a supplementary agreement on the basis of its entity medical institutions, and the related expenses arising from the medical services provided by it in accordance with the scope of medical insurance payment shall be settled in accordance with the provisions of the entity medical institutions on which it relies.
Article 6 A medical institution applying for a fixed point of medical insurance shall have the following basic conditions at the same time: (1) at least 3 months of official operation; (2) at least one physician who has obtained a medical practitioner's certificate, a rural doctor's certificate of practice or a chinese medicine (specialty) medical practitioner's qualification certificate and is first registered in the medical institution; (3) the principal person in charge of medical insurance shall be responsible for medical insurance work and shall be equipped with a special (and) professional medical insurance manager; and 100 beds Medical institutions above the number of places shall set up internal medical insurance management departments and arrange full-time staff; (4) have medical insurance management system, financial system, statistical information management system, medical quality and safety core system, etc. that meet the requirements of medical insurance agreement management; (5) have hospital information system technology and interface standards that meet the requirements of medical insurance agreement management, realize effective docking with medical insurance information system, transmit all relevant information to medical insurance information system according to the requirements, and provide direct network settlement for insured personnel.
Establish basic databases of medical insurance drugs, medical treatment projects, medical service facilities, medical supplies, diseases and other diseases, and use the unified national medical insurance code in accordance with the provisions;
Article 7 Medical institutions shall apply for medical insurance fixed-point to the regional administrative institutions in an integrated area, providing at least the following materials: (1) the application form for fixed-point medical institutions; (2) a copy of the medical institution's license to practise or the chinese medicine clinic's record certificate or the military medical institution's license for civil service; (3) the text of the internal management system and financial system corresponding to the medical insurance policy; (4) the relevant materials related to the information system of medical institutions related to medical insurance; (5) the forecast analysis report on the use of the medical security fund after the fixed-point point; and (6) the other materials required by the provincial medical security administrative departments in accordance with the relevant provisions.
8 medical institutions to file fixed-point applications, the co-ordinating regional agencies shall immediately accept.
the contents of the application materials are incomplete, the agency shall inform the medical institution of the supplement once within 5 working days from the date of receipt of the materials.
Article 9 The co-ordinating regional agencies shall organize assessment teams or entrust third-party organizations to carry out assessments in writing, on-site, etc.
assessment team consists of professionals in medical security, medical and health, financial management, information technology, etc.
from the date of acceptance of the application materials, the evaluation time shall not exceed 3 months, and the time for supplementary materials of medical institutions shall not be included in the evaluation period.
The contents of the assessment include: (1) verifying the license of medical institutions for practice or the record of Chinese medicine clinics or the license of military medical institutions to serve the people; (2) verifying the information of medical practitioners, nurses, pharmacy and medical technicians and other professional and technical personnel and the information of the first place of registration of physicians; and (3) verifying the information of the first place of registration of medical personnel, and (3) verifying the information of the service function. Diagnostics, treatment, surgery, hospitalization, drug storage and distribution, examination and inspection of radiation and other infrastructure and equipment; (4) verification of the internal management system and financial system corresponding to the medical insurance policy, the results of the medical institutions in the health and health departments, and (5) verification of whether the medical institutions related to medical insurance information systems are qualified to carry out direct network settlement.
assessment results are classified as qualified and unqualified.
the administrative department of medical security at the same level shall report the results of the assessment to the administrative department of medical security at the same level for the record.
for the assessment of qualified, it shall be included in the list of medical institutions to be signed an agreement, and made public to the public.
if the assessment is not qualified, it shall inform it of the reasons and make suggestions for rectification.
the date of delivery of the results, after 3 months of rectification, the evaluation may be re-organized, the assessment is still not qualified, and may not be re-applied within 1 year.
provincial medical security administrative departments may, on the basis of these Measures, formulate specific assessment rules according to the actual situation.
10, the two sides voluntarily sign a medical insurance agreement if they negotiate and agree to negotiate with qualified medical institutions.
principle, medical insurance agreements shall be signed with medical institutions by the co-ordinating regional agencies at the municipal level and above and filed with the administrative department of medical security at the same level.
health care agreement should clarify the rights, obligations and responsibilities of both parties.
parties to a medical insurance agreement shall strictly implement the agreement.
agreement is generally one year.
Article 11 The regional operators shall publish to the public the information of the designated medical institutions that have signed the medical insurance agreement, including their names, addresses, etc., for the candidates to choose from.
Article 12 If a medical institution has one of the following circumstances, it shall not accept the application for fixed-point: (1) the non-essential medical services such as medical beauty, assisted reproduction, life care and dental implantation shall be the main scope of practice; (2) the basic medical services shall not implement the medical price policy formulated by the administrative department of medical security; (3) the administrative penalty liability shall not be fulfilled according to law; (4) the application for fixed-point by improper means such as fraud shall not be completed for 3 years from the date of discovery; (5) the medical insurance agreement has not been lifted for 3 years; Or have not fully fulfilled the legal liability for administrative punishment for 3 years; (6) have been discharged from the agreement for a serious violation of the provisions of the medical insurance agreement for not more than one year or have not fully fulfilled their liability for breach of contract; (7) the legal representative, the principal person in charge or the actual controller has been discharged from the medical insurance agreement at the original point due to serious violations of the law, not more than 5 years; (8) the legal representative, the principal person in charge or the actual controller has been included in the list of breach of trust;
Chapter III Operation and Management of Fixed-point Medical Institutions Article 13 Fixed-point medical institutions have the right to obtain medical insurance settlement expenses after providing medical services to insured personnel in accordance with the law, to supervise the performance of the operating institutions, and to make suggestions and suggestions for improving the medical insurance policy. article
The designated medical institutions shall strictly implement the medical insurance agreement, reasonable diagnosis and treatment, reasonable charges, strictly implement the catalogues of medical insurance drugs, medical supplies and medical service items, give priority to the use of medical insurance catalogue drugs, control the proportion of patients at their own expense, and improve the efficiency of the use of medical security funds.
-targeted medical institutions shall not provide medical insurance settlement for non-fixed-point medical institutions.
expenses not paid by the operating institution, the quality deposit deducted by the fixed-point medical institution in accordance with the medical insurance agreement and the default payment, etc., the fixed-point medical institution shall not be treated as a medical insurance arrears. article
The designated medical institutions and their staff shall implement the regulations on the management of real-name medical treatment and drug purchase, verify the valid identification documents of the insured persons, provide reasonable and necessary medical services in accordance with the medical treatment norms, truthfully issue expense documents and related information to the insured persons, shall not decompose the hospitalization, hang the bed in hospital, and shall not violate the The norms of diagnosis and treatment are excessive diagnosis and treatment, over-examination, decomposition of prescriptions, over-prescription of medicines, repeated prescriptions, no repeated charges, over-standard charges, decomposition of project charges, no cross-exchange of drugs, medical supplies, medical treatment items and service facilities, and no inducement or assistance to others under false names or false medical treatment or purchase of drugs.
The designated medical institution shall ensure that the expenses paid by the medical security fund meet the prescribed payment scope, and if medical services outside the scope of payment of the medical security fund are provided except in special circumstances such as emergency or rescue, the consent of the insured person or his next of kin or guardian shall be obtained.
Article 16 Designated medical institutions shall formulate corresponding internal management measures and strictly grasp the signs of entry and exit from hospitals.
shall, in accordance with the agreement, implement the budget targets for the total amount of medical insurance, and implement payment methods by project, by disease, by disease diagnosis, by bed date, by person first class.
may not refuse patients on the grounds of a health insurance payment policy.
17, designated medical institutions shall implement the centralized procurement policy in accordance with the relevant provisions, giving priority to the use of the drugs and consumables selected in the centralized procurement.
and supplies paid for through medical insurance shall be purchased on the platform prescribed by the administrative department of medical security in accordance with the provisions, and the situation of "in, out and out" shall be recorded.
18 Designated medical institutions shall strictly implement the medical price policy formulated by the administrative department of medical security.
19 designated medical institutions shall participate in publicity and training organized by the administrative department of medical security or the agency in which they are run.
designated medical institutions shall organize and carry out training on the relevant systems and policies of the medical security fund, regularly check the use of the medical security fund of the unit, and promptly correct the irregular use of the medical security fund.
20, fixed-point medical institutions shall hang the identification of fixed-point medical institutions in a prominent position. article
Article 21 Fixed-point medical institutions shall, as required, promptly report to the regional operators the settlement list of medical security funds and other information, including diagnosis and operation of diseases, details of the settlement of the expenses of medicines, medical supplies, medical services, doctors, nurses, etc., and shall be responsible for their authenticity.
designated medical institutions shall, as required, truthfully report to the regional agencies that coordinate the procurement price and quantity of medicines and consumables.
designated medical institutions shall report to the medical security department the information required for the supervision and management of the use of the medical security fund and the management of the agreement, and disclose to the public information such as medical expenses and cost structure.
22 Fixed-point medical institutions shall cooperate with the operating institutions in carrying out medical insurance expenses audit, audit inspection, performance appraisal and other work, accept supervision and inspection by the administrative department of medical security, and provide relevant materials in accordance with the provisions.
23 Fixed-point medical institutions shall optimize the medical insurance settlement process, provide convenient medical services for the insured personnel, settle the medical insurance expenses directly in accordance with the provisions, and provide the expense settlement documents and relevant information.
to provide referral services to the insured persons who meet the requirements.
the relevant provisions, the insured person may purchase drugs at a fixed-point medical institution or, by prescription, at a fixed-point retail pharmacy.
24 Designated medical institutions shall do a good job in the security of information systems related to medical insurance, abide by the relevant systems on data security, and protect the privacy of the insured persons.
re-installing the information system, the standard of technical interface of the information system shall be effectively connected with the medical insurance information system, and the relevant data required for the settlement and examination of medical insurance shall be transmitted to the medical insurance information system in a timely and comprehensive manner in accordance with the provisions.
Chapter IV Management Services Article 25 The operating institution shall have the right to grasp the operation and management of fixed-point medical institutions and obtain information and other information and other information required for medical insurance expenses audit, performance appraisal and financial accounting from fixed-point medical institutions.
shall carry out the management of the territory of the fixed-point medical institution, and the administrative service shall be assumed by the administrative institution for the medical services provided by the fixed-point medical institution of the territory for the local and off-location insured personnel.
Article 26 The operating institution shall improve the management process of fixed-point application, organization assessment and agreement signing, agreement fulfillment, agreement change and dissolution, formulate operating procedures, and provide high-quality and efficient operation services for fixed-point medical institutions and insured personnel.
27 The operating institutions shall do a good job in publicity and training on the medical insurance policies, management systems, payment policies and operational procedures of designated medical institutions, and provide medical security consultation and inquiry services.
28 The administrative institution shall implement the policy of payment for medical insurance and strengthen the management of the medical security fund.
Article 29 The operating institution shall establish a sound internal control system and clarify the post responsibilities and risk prevention and control mechanisms for the examination, settlement, allocation and auditing of the declared expenses of fixed-point medical institutions.
improve the collective decision-making system for the expenditure of major medical insurance expenses.
Article 30 The agency shall strengthen medical treatment