Management measures for designated medical institutions of medical insurance issued to expand coverage and tighten supervision

With the Interim Measures for the designated management of medical security in medical institutions (Draft for comments) (hereinafter referred to as the "management measures"), the health insurance regulatory agencies try to promote the compliance of medical institutions with the normalization of supervision, mainly by reducing the access threshold and expanding the coverage of designated medical insurance to reduce the resistance of access, but continue to strengthen in-process supervision and post verification, the cost of violation is far greater than before, so as to promote health insurance The compliance operation of designated institutions can reduce the unreasonable expenses and high incidence of fraud caused by previous violations First of all, from the perspective of expanding coverage, the coverage of Anning treatment and care center and hemodialysis center is clear These two types of institutions can apply for medical insurance fixed point Although it is difficult for independent hemodialysis center to apply for medical insurance before, most of them are affiliated to hospitals for operation However, with the first mock exam allowed, the introduction of rules and regulations will be worth observing, especially in how to approve the medical insurance coverage and reimbursement ratio of independent hemodialysis and hospice care The "management measures" also made it clear once again This means that Internet hospitals are restricted by offline medical institutions, will share the medical insurance quota with offline medical institutions, and the reimbursement proportion may also be gradually consistent Because the total amount of medical insurance is consistent with the business capacity of offline hospitals, and the medical institutions with stronger offline business will have higher medical insurance quota, the Internet hospitals on the basis of which can be expanded by medical insurance, while the platform Internet enterprises need to rely on the medical insurance quota of offline medical institutions, which obviously restricts its scalability As for the development of independent medical laboratory, the management measures made it clear that it could not get medical insurance fixed point by itself This means that medical insurance recognizes that independent third-party inspection institutions can obtain medical insurance payment for services provided, but the settlement is with designated medical institutions rather than directly with medical insurance On the one hand, it avoids restricting the third-party inspection institutions to undertake other non-medical insurance projects; on the other hand, it helps to supervise the relevant inspection services of medical institutions, and the medical insurance will also check the third-party inspection institutions' medical insurance related services Secondly, from the perspective of in-process supervision, the designated medical institutions need to pay according to the payment methods and standards of medical insurance, among which three points deserve attention: first, in Article 16, it is stipulated that the "medical insurance payment system" shall be adopted At the end of each year, the medical institutions often shirk the responsibility of medical insurance patients On the one hand, it is the growth of medical demand, on the other hand, it is caused by the lack of fine management ability of the hospital itself With the strengthening of the fine management of medical insurance, this will lead to the improvement of the fine management ability of the hospital, so as to avoid the occurrence of such things as prevarication of patients Second, it is the requirement for centralized purchase to become a designated medical institution for medical insurance This means that as long as medical insurance is used, regardless of the nature of medical institutions, it is necessary to give priority to the use of centralized drugs and consumables, and purchase them on the platform approved by medical insurance This policy has a great influence on private hospitals As private medical institutions mainly rely on drugs and consumables to obtain profits, with the reduction of profits due to centralized purchase, private medical institutions need more services Third, the establishment of medical insurance agreement doctors "" Doctor under medical insurance agreement refers to the doctor who signs the medical insurance service agreement with the medical insurance agency The medical insurance agency implements the cumulative assessment management for the medical insurance doctor If the doctor violates the medical insurance regulations, the score will be deducted According to the deducted score of the current year, the relevant punishment measures will be determined, and the highest medical insurance qualification can be cancelled This is the main means of micro management for doctors in medical insurance In addition to the total prepayment and DRG, individual management has been added to achieve three-dimensional management Finally, from the perspective of post inspection, in addition to the previously emphasized supervision and inspection, there is one thing worthy of attention in the two parts of operation management and supervision in the management measures, one is the emphasis on performance appraisal, the other is the requirement of innovative supervision mode Although the performance appraisal of designated medical institutions was also carried out before, but the constraint was relatively weak, and the management measures emphasized that: "the performance appraisal of designated medical institutions is a kind of performance appraisal This means that the performance appraisal will be related to the current year and the next year's quota of medical insurance and whether to renew it, and there is the last elimination system Once the appraisal result is at the bottom, the hospital's medical insurance qualification will be cancelled This will put some pressure on medical institutions, especially in the next year's medical insurance quota, which may not be the same as before, as long as the total amount of the current year is spent, the next year will be expanded, but will be based on the assessment results In terms of innovation and supervision mode“