Interpretation of the policy of the Measures for Reporting Rewards for the Illegal Use of Medical Security Funds

Recently, the National Health Insurance Administration and the Ministry of Finance jointly formulated the Measures for Reporting Rewards for the Illegal Use of Medical Security Funds (hereinafter referred to as the "Incentive Measures"), which will be officially implemented
on January 1, 2023.
The Incentive Measures are interpreted as follows
.

 

I.
Background to the introduction of the Incentive Measures

 

Since its establishment, the National Health Insurance Administration has resolutely implemented the decision-making and deployment of the Party Central Committee and the State Council, always regarded maintaining the safety of medical insurance funds as the primary task, continuously explored innovative fund supervision methods, and actively encouraged and supported all sectors of society to participate in fund supervision
.
In November 2018, the National Health Insurance Administration and the Ministry of Finance jointly issued the Interim Measures for Reporting Rewards for Fraud and Fraud in Medical Security Funds (hereinafter referred to as the "Original Incentive Measures"), establishing a reward system
for reporting fraud and insurance fraud.

 

The system has played an important role
in mobilizing social forces to participate in fund supervision and maintaining the safety of medical insurance funds.
At present, 31 provinces (autonomous regions and municipalities directly under the central government) and the Xinjiang Production and Construction Corps have established corresponding reporting reward systems, which has promoted the benign interaction between government supervision and social supervision, and created a good atmosphere
of social co-governance and sharing of fund supervision.
The general public's awareness of supervision has been continuously improved, and they have actively participated in the supervision of medical insurance funds, and the number of people reporting and rewarding, the amount of rewards issued, and the amount of violations investigated and dealt with have increased year by year, and the role of social supervision in combating fraud and insurance fraud has become increasingly significant
.
Medical insurance departments at all levels have successively rewarded more than 2,570 whistleblowers and issued nearly 5 million yuan in whistleblowing rewards, and Tianjin, Zhejiang, Guangxi and other three provinces (autonomous regions and municipalities) received a maximum reward of 100,000 yuan for a single person, and verified and recovered 158 million yuan
of medical insurance violations according to the relevant public reporting clues.

 

In recent years, with the in-depth advancement of national fund supervision, laws and regulations in the field of fund supervision have been continuously improved, especially the promulgation of regulations and rules such as the Regulations on the Supervision and Administration of the Use of Medical Security Funds and the Interim Measures for the Handling of Reports on the Supervision and Management of the Use of Medical Security Funds, comprehensively building a three-dimensional fund supervision system including social supervision, and at the same time clearly including all illegal use of medical insurance funds into the scope of
reporting 。 In order to further adapt to the new situation of fund supervision, fully mobilize the masses, rely on the masses, encourage the masses to participate in the supervision of medical insurance funds, continue to strengthen the role of social supervision, and jointly protect the people's "medical money" and "life-saving money", the National Health Insurance Administration and the Ministry of Finance have revised
the "Original Reward Measures" in accordance with relevant laws and regulations and the actual situation of local reporting and reward work.

 

2.
The main contents of the Incentive Measures and their purpose and significance

 

As a supporting document of the Interim Measures for the Supervision and Management of the Use of Medical Security Funds, the Reward Measures contain 15 articles, which stipulate the purpose basis and scope of application of the whistleblowing reward system, as well as the principles, conditions, standards, issuance, receipt, redemption and recovery of rewards, and also fully reflect the considerations
in deepening the reward reporting system and encouraging the public to participate in supervision.

 

(1) Earnestly expand the scope, raise standards, and actively encourage the masses to participate in social supervision
.

 

As China's efforts to combat insurance fraud continue to increase, "blatant" insurance fraud has been effectively curbed, and some insurance fraud has shifted from front to back, and gradually changed
to violations such as excessive diagnosis and treatment, and excessive standard charges.
The means of violations of laws and regulations in the medical insurance field are more hidden, counterfeiting is more professional, and the forms are more diverse, relying only on the unilateral power of the medical insurance department, it is difficult to detect these mutated insurance fraud behaviors of "wearing invisibility clothing" and "hiding in green yarn
tents" 。 In order to further mobilize the enthusiasm of the masses for reporting, expand the scope of public reporting, continue to strengthen the important role of social supervision in combating violations of laws and regulations, effectively weave a dense fund supervision network, and effectively build a social co-governance pattern, the Reward Measures clearly include all reports of illegal use of medical insurance funds into the scope of rewards, and combine the actual situation of each locality, stipulate that a one-time reward
will be given to whistleblowers according to a certain proportion of the value of the case 。 At the same time, the upper limit of the reward amount was raised from 100,000 yuan to 200,000 yuan, and a minimum minimum reward amount of 200 yuan was set to give full play to the role of rewards and incentives, and actively encourage and guide the public to participate in social supervision
.

 

(2) Persist in unblocking channels and optimizing processes, effectively facilitating the people's participation in social supervision
.

 

In order to facilitate the public to report, medical insurance departments at all levels have announced a variety of reporting channels such as the Internet, telephone, fax, and mail, and whistleblowers can choose any way to report according to their own actual conditions, all of which meet the basic conditions
for receiving rewards.
In practice, the medical insurance department shall register the reported information received, implement whole-process management of the reporting leads, and handle it in strict accordance with the Regulations on the Supervision and Administration of the Use of Medical Security Funds and other relevant provisions, and at the same time simplify the process and open up convenient channels for the payment of rewards in accordance with the relevant provisions of the Reward Measures, so as to standardize and facilitate the whistleblower to receive the reporting reward
to the greatest extent 。 In addition, in order to cooperate with the promulgation and implementation of the "Reward Measures", the National Health Insurance Administration has specially developed and used a reporting and complaint management system on the national medical security information platform, striving to carry out the whole process, whole chain and all-round accurate management of reporting leads in various channels.
On the other hand, timely supervise local medical insurance departments to issue reporting rewards on time and in full, and ensure that rewards must be awarded
.
At present, the system has been piloted in Hebei, Zhejiang and Jiangxi provinces, and will be promoted and used
nationwide when the conditions are ripe.

 

(3) Strengthen case confidentiality and information security, and resolutely protect the people's rights and interests
in participating in social oversight.

 

The Reward Measures emphasize that the lawful rights and interests of whistleblowers are protected in accordance with the law, and medical insurance departments at all levels shall keep the information of informants confidential, and must not disclose the personal information and circumstances of the informant to the reported person or persons
unrelated to the handling of the report.
In practice, mass reports can be made in real names or anonymously
.
The medical insurance department encourages informants to report in their real names, and if the informant reports in his real name, he or she shall provide his or her real identity information and true and effective contact information
when making the report.
The medical insurance department shall keep the information of real-name whistleblowers strictly confidential
.
If the informant reports anonymously and is willing to receive the reward, he or she may promptly provide relevant information such as his identity certificate and bank account after the medical insurance department notifies him of receiving the reward (the real and effective contact information is provided at the time of reporting), so that the medical insurance department can cash the reward
after verification.
For the reward distribution procedures for anonymous reports, the medical security administrative departments and financial departments at the provincial and municipal levels may make specific provisions
when formulating implementation rules.

 

(4) Strictly investigate and reward reports, and positively guide the people to participate in social supervision
.

 

Whistleblowers shall be responsible for the authenticity of the content of the report and the materials provided, and where they fabricate or distort the facts, or falsely accuse and frame others, they shall bear relevant legal responsibility
in accordance with law.
Medical insurance and medical care have never been antagonistic relationships, they are interdependent, mutually restrictive, and develop in a coordinated manner, and work together to safeguard the health of the people
.
While encouraging the public to report the illegal use of medical insurance funds, we emphasize the need to protect the legitimate rights and interests
of designated medical institutions in accordance with the law.
In response to relevant reporting leads, the medical insurance department should comprehensively verify, conduct in-depth analysis, remove falsifications and seek truth, and neither investigate in general terms or stop in a superficial manner, nor make a presumption of guilt on the reported object, let alone indiscriminately issue and indiscriminately issue reporting rewards
.
The "Reward Measures" stipulates that the medical insurance department shall conduct strict review of the reward issued by the medical insurance department, and clarify that the medical insurance department has the right to withdraw the reward and pursue the responsibility of relevant personnel in accordance with the law for the whistleblower who fraudulently obtains the reward by falsifying materials or concealing facts, so as to promote the people's lawful and lawful reporting
.

 

3.
Explanation of other matters

 

(1) Can whistleblowers be rewarded for reporting to the medical insurance agency?

 

In practice, the whistleblower may not be able to accurately distinguish between the medical insurance administrative department and the medical insurance handling institution, so when reporting the illegal use of medical insurance funds, there are cases
where the report is made directly to the medical insurance handling institution.
In this case, if the medical insurance administrative department has entrusted the medical insurance handling institution to organize and carry out the report handling work, the medical insurance handling institution should handle the report in accordance with the relevant procedures; If the medical insurance administrative department does not entrust the medical insurance handling institution to organize the handling of the report, the medical insurance handling institution shall guide the whistleblower to report to the medical insurance administrative department or transfer the relevant reporting materials
to the medical insurance administrative department.
Therefore, the whistleblower reports to the medical insurance agency that the basic conditions
for receiving the reward are met.

 

(2) Can social supervisors receive rewards for reporting?

 

The Guiding Opinions of the General Office of the State Council on Promoting the Reform of the Medical Security Fund Supervision System points out that a system of social supervisors for medical insurance funds should be established, and people's congress deputies, CPPCC members, representatives of the masses and news media should be hired as social supervisors, and extensive and in-depth supervision
of designated medical institutions, handling institutions, and insured personnel should be carried out.
Relevant documents such as the Interim Measures for the Designated Management of Medical Security for Medical Institutions and the Interim Measures for the Designated Management of Medical Security in Retail Pharmacies stipulate that medical security administrative departments and handling institutions shall conduct social supervision
over designated medical institutions by hiring social supervisors and other means.
Judging from the current regulations, social supervisors' reporting falls within the scope of social supervision, so they meet the basic conditions
for receiving rewards.

 

(3) Are the fund losses involved in the direct settlement of medical treatment in different places included in the calculation of the case value?

 

Incorporated
.
In accordance with the relevant medical insurance policies, the direct settlement of medical treatment in different places implements the supervision of the place of medical treatment, and the handling of complaints and reports follows the principle of
territorial management.
The "Reward Measures" stipulates that the medical security administrative department handling the report shall be responsible for issuing the whistleblowing reward, and the whistleblower who meets the reward conditions shall be rewarded according to a certain proportion of the case value, and at the same time points out that the case value refers to the amount of medical insurance fund loss that should be recovered involved in the reported matter, and this concept actually includes the fund loss
involved in the direct settlement of medical treatment in different places.

 

(4) How to formulate specific award standards?

 

The "Incentive Measures" stipulates the upper and lower limits of the amount of incentives, because taking into account factors such as the inconsistency of the level of economic development in various places, there is no unified provision for specific award standards, and the provincial and municipal medical security administrative departments and financial departments may make specific provisions
on the award standards within the framework of these Measures in light of the actual local conditions.
When formulating specific reward standards, each region may separately set reward standards
based on situations such as the different value of the reported leads in case investigation, different methods of handling violations (agreements, administrative, judicial, etc.
), different amounts of violations, and different nature of violations and violations.