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On September 6, the National Medical Insurance Administration announced the Interim Measures for the Administration of Medical Security Audit (Draft for Solicitation of Comments) (hereinafter referred to as the “Interim Measures”) to solicit opinions from the public.
The deadline for feedback is October 6, 2021
.
The deadline for feedback is October 6, 2021
.
There are six chapters and 46 articles in the Interim Measures, which not only clarify the basic ideas and principles of medical security audit work as a whole, and the duties and division of duties of medical insurance agencies at all levels in the audit work, but also on the audit responsibilities, audit types and methods, Detailed regulations have been made for the specific links in the audit work such as audit implementation, result processing and application
.
.
According to the Interim Measures, the medical security audit refers to the implementation of medical insurance agreements by medical insurance agencies for designated medical institutions, designated retail pharmacies and other designated medical institutions in accordance with laws and regulations, the status of medical insurance benefits enjoyed by insured persons, and the use of medical security funds by other units and individuals.
Check the situation
.
Check the situation
.
Since the establishment of the National Medical Insurance Administration, whether it is the power of Thunder to rectify fraudulent medical insurance fund behaviors, or to improve related laws and regulations, the advancement is fast and vigorous.
With the announcement of the interim measures, plus the earlier Security Law (Draft for Solicitation of Comments) and the Interim Measures for the Administration of the Two Designated Institutions and other regulatory policies, it can be said that the medical insurance supervision network is gradually established, and the designated medical institutions will usher in the most stringent supervision era
.
With the announcement of the interim measures, plus the earlier Security Law (Draft for Solicitation of Comments) and the Interim Measures for the Administration of the Two Designated Institutions and other regulatory policies, it can be said that the medical insurance supervision network is gradually established, and the designated medical institutions will usher in the most stringent supervision era
.
01 Implementation of medical insurance agencies at or above the county level
Article 4 of the Interim Measures mentions that medical security audits are specifically implemented by medical security agencies at or above the county level
.
Provincial-level agencies provide guidance on the audit work of municipal and county-level agencies
.
Management agencies at all levels should strengthen joint collaboration, exchange and share information, and conduct inspections on the same subject under audit at the same time to avoid duplication and multiple inspections
.
.
Provincial-level agencies provide guidance on the audit work of municipal and county-level agencies
.
Management agencies at all levels should strengthen joint collaboration, exchange and share information, and conduct inspections on the same subject under audit at the same time to avoid duplication and multiple inspections
.
02Equipped with professional auditors
In terms of audit staff, Article 6 of the Interim Measures states that handling agencies should strengthen the construction of medical security auditing capabilities, allocate staff, and hire relevant agencies and professionals to assist in inspections according to work needs; qualified provincial, municipal, and county medical services The security department may set up an independent medical security audit institution to undertake the medical security audit work
.
.
This can be seen as a signal for the construction of a professional management team, which is consistent with the establishment of professional inspectors by the State Food and Drug Administration.
This not only ensures the professional justice of the audit work, but also ensures the systematization of the audit work
.
According to data from the State Food and Drug Administration, as of the end of 2020, the number of qualified drug GMP inspectors was 842, the number of qualified drug GSP inspectors was 11,925, and the number of qualified medical device GMP inspectors was 3639, effectively This guarantees the development of the supervision of medical devices
.
This not only ensures the professional justice of the audit work, but also ensures the systematization of the audit work
.
According to data from the State Food and Drug Administration, as of the end of 2020, the number of qualified drug GMP inspectors was 842, the number of qualified drug GSP inspectors was 11,925, and the number of qualified medical device GMP inspectors was 3639, effectively This guarantees the development of the supervision of medical devices
.
It is clear from the Interim Measures that medical security auditors should have the following requirements: obtain relevant certificates for conducting medical security audits; be familiar with medical security business and related laws, regulations and policies, and have the corresponding ability to conduct audits; adhere to principles and have a decent work >
.
.
03The audit content involves purchase, sales and inventory data
The Interim Measures mentioned that the implementation of medical security audits is divided into six aspects, including the implementation of medical insurance agreements by designated medical institutions and the implementation of medical security policies, including medical treatment and drug purchase management, medical services, price management, payment scope, and payment standards , Payment methods, fee settlement and other regulations
.
.
In addition, the designated medical institutions fulfill the medical insurance agreement and use the data and materials of the medical security fund, including the medical security fund settlement list, the "purchasing, selling, and storing" data of medicines and medical consumables, and the prescriptions and materials related to the settlement of the medical security fund.
medical records, inspection records treatment, cost breakdown, accounting documents, financial accounts and so on
.
medical records, inspection records treatment, cost breakdown, accounting documents, financial accounts and so on
.
The Interim Measures also mentioned that the audit work also includes the medical service items, medicines, medical consumables and other expenses that the designated medical institutions apply to the handling institutions for payment
.
.
04 Audit types include daily audits, special audits, and key audits
The types of medical security audits mainly include: daily audits, special audits, and key audits
.
Audit methods include online, on-site, written, and inquiry methods
.
.
Audit methods include online, on-site, written, and inquiry methods
.
Among them, on-site audit refers to the use of on-site audit methods to conduct audits on designated medical institutions, related units and personnel, and the handling agency conducts investigations and evidence collection by consulting and obtaining materials, inspecting the site, and inquiring relevant personnel, as an audit conclusion.
Basis
.
For individuals, smart devices such as biometrics can be used to collect audit information or evidence
.
Basis
.
For individuals, smart devices such as biometrics can be used to collect audit information or evidence
.
The audited object is the audited object when inspecting and copying the audited object’s medical security fund settlement related materials (financial accounts, personnel expenditures, accounting vouchers, prescriptions, medical records, treatment inspection records, cost details, records of drugs and medical consumables in and out of the warehouse, etc.
) on the spot They should cooperate and provide relevant materials and information truthfully
.
) on the spot They should cooperate and provide relevant materials and information truthfully
.
If the designated medical institution does not have working conditions such as on-site inspection, copying of electronic and paper medical records, the auditors can review relevant materials and fill in the medical security audit review form.
After the two parties have checked and checked, the auditors and the audited object the legal representative (legal representative or delegate agency people) signed or stamped on Medicare audit tune single trial
.
After the two parties have checked and checked, the auditors and the audited object the legal representative (legal representative or delegate agency people) signed or stamped on Medicare audit tune single trial
.
05 Penalty: the highest criminal liability
The Interim Measures propose that if the handling agency discovers that the designated medical institution has violated the agreement, it should urge the designated medical institution to make corrections based on the audit results, and take the following handling methods according to the agreement:
(1) Interview with the legal representative, main responsible person or actual controller of the designated medical institution;
(2) Suspending or not appropriating payment fees;
(3) Failing to pay or recover the paid medical insurance expenses;
(4) Require designated medical institutions to pay liquidated damages in accordance with the agreement;
(5) Discontinue the medical services of the relevant responsible person or the department involved in the use of the medical security fund;
(6) Suspend or terminate the medical insurance agreement
.
.
If any insurance fraud is suspected of causing losses to the medical security fund, the handling agency shall promptly report to the medical security administrative department for further processing
.
.
It is worth noting that the "Medical Security Law (Draft for Comment)" mentioned that "if the provisions of this law are violated and constitute a crime, criminal responsibility shall be investigated in accordance with the law
.
"
.
"
On September 6, the National Medical Insurance Administration announced the Interim Measures for the Administration of Medical Security Audit (Draft for Solicitation of Comments) (hereinafter referred to as the “Interim Measures”) to solicit opinions from the public.
The deadline for feedback is October 6, 2021
.
The deadline for feedback is October 6, 2021
.
There are six chapters and 46 articles in the Interim Measures, which not only clarify the basic ideas and principles of medical security audit work as a whole, and the duties and division of duties of medical insurance agencies at all levels in the audit work, but also on the audit responsibilities, audit types and methods, Detailed regulations have been made for the specific links in the audit work such as audit implementation, result processing and application
.
.
According to the Interim Measures, the medical security audit refers to the implementation of medical insurance agreements by medical insurance agencies for designated medical institutions, designated retail pharmacies and other designated medical institutions in accordance with laws and regulations, the status of medical insurance benefits enjoyed by insured persons, and the use of medical security funds by other units and individuals.
Check the situation
.
Check the situation
.
Since the establishment of the National Medical Insurance Administration, whether it is the power of Thunder to rectify fraudulent medical insurance fund behaviors, or to improve related laws and regulations, the advancement is fast and vigorous.
With the announcement of the interim measures, plus the earlier Security Law (Draft for Solicitation of Comments) and the Interim Measures for the Administration of the Two Designated Institutions and other regulatory policies, it can be said that the medical insurance supervision network is gradually established, and the designated medical institutions will usher in the most stringent supervision era
.
With the announcement of the interim measures, plus the earlier Security Law (Draft for Solicitation of Comments) and the Interim Measures for the Administration of the Two Designated Institutions and other regulatory policies, it can be said that the medical insurance supervision network is gradually established, and the designated medical institutions will usher in the most stringent supervision era
.
01 Implementation of medical insurance agencies at or above the county level
Article 4 of the Interim Measures mentions that medical security audits are specifically implemented by medical security agencies at or above the county level
.
Provincial-level agencies provide guidance on the audit work of municipal and county-level agencies
.
Management agencies at all levels should strengthen joint collaboration, exchange and share information, and conduct inspections on the same subject under audit at the same time to avoid duplication and multiple inspections
.
.
Provincial-level agencies provide guidance on the audit work of municipal and county-level agencies
.
Management agencies at all levels should strengthen joint collaboration, exchange and share information, and conduct inspections on the same subject under audit at the same time to avoid duplication and multiple inspections
.
02Equipped with professional auditors
In terms of audit staff, Article 6 of the Interim Measures states that handling agencies should strengthen the construction of medical security auditing capabilities, allocate staff, and hire relevant agencies and professionals to assist in inspections according to work needs; qualified provincial, municipal, and county medical services The security department may set up an independent medical security audit institution to undertake the medical security audit work
.
.
This can be seen as a signal for the construction of a professional management team, which is consistent with the establishment of professional inspectors by the State Food and Drug Administration.
This not only ensures the professional justice of the audit work, but also ensures the systematization of the audit work
.
According to data from the State Food and Drug Administration, as of the end of 2020, the number of qualified drug GMP inspectors was 842, the number of qualified drug GSP inspectors was 11,925, and the number of qualified medical device GMP inspectors was 3639, effectively This guarantees the development of the supervision of medical devices
.
This not only ensures the professional justice of the audit work, but also ensures the systematization of the audit work
.
According to data from the State Food and Drug Administration, as of the end of 2020, the number of qualified drug GMP inspectors was 842, the number of qualified drug GSP inspectors was 11,925, and the number of qualified medical device GMP inspectors was 3639, effectively This guarantees the development of the supervision of medical devices
.
It is clear from the Interim Measures that medical security auditors should have the following requirements: obtain relevant certificates for conducting medical security audits; be familiar with medical security business and related laws, regulations and policies, and have the corresponding ability to conduct audits; adhere to principles and have a decent work >
.
.
03The audit content involves purchase, sales and inventory data
The Interim Measures mentioned that the implementation of medical security audits is divided into six aspects, including the implementation of medical insurance agreements by designated medical institutions and the implementation of medical security policies, including medical treatment and drug purchase management, medical services, price management, payment scope, and payment standards , Payment methods, fee settlement and other regulations
.
.
In addition, the designated medical institutions fulfill the medical insurance agreement and use the data and materials of the medical security fund, including the medical security fund settlement list, the "purchasing, selling, and storing" data of medicines and medical consumables, and the prescriptions and materials related to the settlement of the medical security fund.
medical records, inspection records treatment, cost breakdown, accounting documents, financial accounts and so on
.
medical records, inspection records treatment, cost breakdown, accounting documents, financial accounts and so on
.
The Interim Measures also mentioned that the audit work also includes the medical service items, medicines, medical consumables and other expenses that the designated medical institutions apply to the handling institutions for payment
.
.
04 Audit types include daily audits, special audits, and key audits
The types of medical security audits mainly include: daily audits, special audits, and key audits
.
Audit methods include online, on-site, written, and inquiry methods
.
.
Audit methods include online, on-site, written, and inquiry methods
.
Among them, on-site audit refers to the use of on-site audit methods to conduct audits on designated medical institutions, related units and personnel, and the handling agency conducts investigations and evidence collection by consulting and obtaining materials, inspecting the site, and inquiring relevant personnel, as an audit conclusion.
Basis
.
For individuals, smart devices such as biometrics can be used to collect audit information or evidence
.
Basis
.
For individuals, smart devices such as biometrics can be used to collect audit information or evidence
.
The audited object is the audited object when inspecting and copying the audited object’s medical security fund settlement related materials (financial accounts, personnel expenditures, accounting vouchers, prescriptions, medical records, treatment inspection records, cost details, records of drugs and medical consumables in and out of the warehouse, etc.
) on the spot They should cooperate and provide relevant materials and information truthfully
.
) on the spot They should cooperate and provide relevant materials and information truthfully
.
If the designated medical institution does not have working conditions such as on-site inspection, copying of electronic and paper medical records, the auditors can review relevant materials and fill in the medical security audit review form.
After the two parties have checked and checked, the auditors and the audited object the legal representative (legal representative or delegate agency people) signed or stamped on Medicare audit tune single trial
.
After the two parties have checked and checked, the auditors and the audited object the legal representative (legal representative or delegate agency people) signed or stamped on Medicare audit tune single trial
.
05 Penalty: the highest criminal liability
The Interim Measures propose that if the handling agency discovers that the designated medical institution has violated the agreement, it should urge the designated medical institution to make corrections based on the audit results, and take the following handling methods according to the agreement:
(1) Interview with the legal representative, main responsible person or actual controller of the designated medical institution;
(2) Suspending or not appropriating payment fees;
(3) Failing to pay or recover the paid medical insurance expenses;
(4) Require designated medical institutions to pay liquidated damages in accordance with the agreement;
(5) Discontinue the medical services of the relevant responsible person or the department involved in the use of the medical security fund;
(6) Suspend or terminate the medical insurance agreement
.
.
If any insurance fraud is suspected of causing losses to the medical security fund, the handling agency shall promptly report to the medical security administrative department for further processing
.
.
It is worth noting that the "Medical Security Law (Draft for Comment)" mentioned that "if the provisions of this law are violated and constitute a crime, criminal responsibility shall be investigated in accordance with the law
.
"
.
"
On September 6, the National Medical Insurance Administration announced the Interim Measures for the Administration of Medical Security Audit (Draft for Solicitation of Comments) (hereinafter referred to as the “Interim Measures”) to solicit opinions from the public.
The deadline for feedback is October 6, 2021
.
The deadline for feedback is October 6, 2021
.
There are six chapters and 46 articles in the Interim Measures, which not only clarify the basic ideas and principles of medical security audit work as a whole, and the duties and division of duties of medical insurance agencies at all levels in the audit work, but also on the audit responsibilities, audit types and methods, Detailed regulations have been made for the specific links in the audit work such as audit implementation, result processing and application
.
.
According to the Interim Measures, the medical security audit refers to the implementation of medical insurance agreements by medical insurance agencies for designated medical institutions, designated retail pharmacies and other designated medical institutions in accordance with laws and regulations, the status of medical insurance benefits enjoyed by insured persons, and the use of medical security funds by other units and individuals.
Check the situation
.
Pharmacy pharmacy pharmacyCheck the situation
.
Since the establishment of the National Medical Insurance Administration, whether it is the power of Thunder to rectify fraudulent medical insurance fund behaviors, or to improve related laws and regulations, the advancement is fast and vigorous.
With the announcement of the interim measures, plus the earlier Security Law (Draft for Solicitation of Comments) and the Interim Measures for the Administration of the Two Designated Institutions and other regulatory policies, it can be said that the medical insurance supervision network is gradually established, and the designated medical institutions will usher in the most stringent supervision era
.
With the announcement of the interim measures, plus the earlier Security Law (Draft for Solicitation of Comments) and the Interim Measures for the Administration of the Two Designated Institutions and other regulatory policies, it can be said that the medical insurance supervision network is gradually established, and the designated medical institutions will usher in the most stringent supervision era
.
01 Implementation of medical insurance agencies at or above the county level
01 Implementation of medical insurance agencies at or above the county level Article 4 of the Interim Measures mentions that medical security audits are specifically implemented by medical security agencies at or above the county level
.
Provincial-level agencies provide guidance on the audit work of municipal and county-level agencies
.
Management agencies at all levels should strengthen joint collaboration, exchange and share information, and conduct inspections on the same subject under audit at the same time to avoid duplication and multiple inspections
.
.
Provincial-level agencies provide guidance on the audit work of municipal and county-level agencies
.
Management agencies at all levels should strengthen joint collaboration, exchange and share information, and conduct inspections on the same subject under audit at the same time to avoid duplication and multiple inspections
.
02Equipped with professional auditors
02Equipped with professional auditors In terms of audit staff, Article 6 of the Interim Measures states that handling agencies should strengthen the construction of medical security auditing capabilities, allocate staff, and hire relevant agencies and professionals to assist in inspections according to work needs; qualified provincial, municipal, and county medical services The security department may set up an independent medical security audit institution to undertake the medical security audit work
.
.
This can be seen as a signal for the construction of a professional management team, which is consistent with the establishment of professional inspectors by the State Food and Drug Administration.
This not only ensures the professional justice of the audit work, but also ensures the systematization of the audit work
.
According to data from the State Food and Drug Administration, as of the end of 2020, the number of qualified drug GMP inspectors was 842, the number of qualified drug GSP inspectors was 11,925, and the number of qualified medical device GMP inspectors was 3639, effectively This guarantees the development of the supervision of medical devices
.
Medicines Medicines Medicines Medical Devices Medical Devices Medical DevicesThis not only ensures the professional justice of the audit work, but also ensures the systematization of the audit work
.
According to data from the State Food and Drug Administration, as of the end of 2020, the number of qualified drug GMP inspectors was 842, the number of qualified drug GSP inspectors was 11,925, and the number of qualified medical device GMP inspectors was 3639, effectively This guarantees the development of the supervision of medical devices
.
It is clear from the Interim Measures that medical security auditors should have the following requirements: obtain relevant certificates for conducting medical security audits; be familiar with medical security business and related laws, regulations and policies, and have the corresponding ability to conduct audits; adhere to principles and have a decent work >
.
.
03The audit content involves purchase, sales and inventory data
03The audit content involves purchase, sales and inventory data The Interim Measures mentioned that the implementation of medical security audits is divided into six aspects, including the implementation of medical insurance agreements by designated medical institutions and the implementation of medical security policies, including medical treatment and drug purchase management, medical services, price management, payment scope, and payment standards , Payment methods, fee settlement and other regulations
.
Medicine Medicine Medicine.
In addition, the designated medical institutions fulfill the medical insurance agreement and use the data and materials of the medical security fund, including the medical security fund settlement list, the "purchasing, selling, and storing" data of medicines and medical consumables, and the prescriptions and materials related to the settlement of the medical security fund.
medical records, inspection records treatment, cost breakdown, accounting documents, financial accounts and so on
.
medical records, inspection records treatment, cost breakdown, accounting documents, financial accounts and so on
.
The Interim Measures also mentioned that the audit work also includes the medical service items, medicines, medical consumables and other expenses that the designated medical institutions apply to the handling institutions for payment
.
.
04 Audit types include daily audits, special audits, and key audits
04 Audit types include daily audits, special audits, and key audits The types of medical security audits mainly include: daily audits, special audits, and key audits
.
Audit methods include online, on-site, written, and inquiry methods
.
.
Audit methods include online, on-site, written, and inquiry methods
.
Among them, on-site audit refers to the use of on-site audit methods to conduct audits on designated medical institutions, related units and personnel, and the handling agency conducts investigations and evidence collection by consulting and obtaining materials, inspecting the site, and inquiring relevant personnel, as an audit conclusion.
Basis
.
For individuals, smart devices such as biometrics can be used to collect audit information or evidence
.
Basis
.
For individuals, smart devices such as biometrics can be used to collect audit information or evidence
.
The audited object is the audited object when inspecting and copying the audited object’s medical security fund settlement related materials (financial accounts, personnel expenditures, accounting vouchers, prescriptions, medical records, treatment inspection records, cost details, records of drugs and medical consumables in and out of the warehouse, etc.
) on the spot They should cooperate and provide relevant materials and information truthfully
.
) on the spot They should cooperate and provide relevant materials and information truthfully
.
If the designated medical institution does not have working conditions such as on-site inspection, copying of electronic and paper medical records, the auditors can review relevant materials and fill in the medical security audit review form.
After the two parties have checked and checked, the auditors and the audited object the legal representative (legal representative or delegate agency people) signed or stamped on Medicare audit tune single trial
.
Agent Agent AgentAfter the two parties have checked and checked, the auditors and the audited object the legal representative (legal representative or delegate agency people) signed or stamped on Medicare audit tune single trial
.
05 Penalty: the highest criminal liability
05 Penalty: the highest criminal liability The Interim Measures propose that if the handling agency discovers that the designated medical institution has violated the agreement, it should urge the designated medical institution to make corrections based on the audit results, and take the following handling methods according to the agreement:
(1) Interview with the legal representative, main responsible person or actual controller of the designated medical institution;
(2) Suspending or not appropriating payment fees;
(3) Failing to pay or recover the paid medical insurance expenses;
(4) Require designated medical institutions to pay liquidated damages in accordance with the agreement;
(5) Discontinue the medical services of the relevant responsible person or the department involved in the use of the medical security fund;
(6) Suspend or terminate the medical insurance agreement
.
.
If any insurance fraud is suspected of causing losses to the medical security fund, the handling agency shall promptly report to the medical security administrative department for further processing
.
.
It is worth noting that the "Medical Security Law (Draft for Comment)" mentioned that "if the provisions of this law are violated and constitute a crime, criminal responsibility shall be investigated in accordance with the law
.
"
.
"
