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In order to further unify and standardize the flight inspection mechanism, optimize the flight inspection work procedures, and strengthen the supervision
of medical security funds in accordance with the law.
On November 24, the National Health Insurance Administration issued the Interim Measures for the Administration of Flight Inspection of Medical Security Funds (Draft for Comments) (hereinafter referred to as the Draft for Comments), which was once again open to the public for comments
.
In July 2019, the National Health Insurance Administration issued the Regulations for Supervision of Flight Inspection of Medical Security Fund, and carried out regular flight inspections nationwide, achieving remarkable results, but there are still some shortcomings
.
In order to meet the higher requirements of the Regulations on the Supervision and Administration of the Use of Medical Security Funds and other higher requirements for investigating and punishing illegal use of medical security funds in accordance with the law, the National Health Insurance Administration formed the Draft for Comments on the basis of extensive research and solicitation of
opinions 。
The medical insurance "flight inspection" is then upgraded
Strictly block loopholes in the use of funds
In the industry's view, as the National Health Insurance Administration continues to strengthen the supervision of medical insurance funds and continuously improve the supervision system and mechanism of medical insurance funds, the formation of the Draft for Comments will further improve the punishment for investigating and punishing illegal use of medical security funds in accordance with the law, focus on improving the quality of medical security work, and protect the legitimate rights and interests of
patients.
The national level has made important arrangements for fund supervision on many occasions, clearly requiring strengthening the supervision of the use of medical insurance funds, and unswervingly cracking down on fraud and insurance fraud
.
The Draft consists of 32 articles in 5 chapters, the main contents of which include:
Chapter 1 General Provisions clarifies the definition, principles, and participation mechanisms of flight
inspections.
It stipulates that the level of organization and implementation of flight inspections is the national and provincial medical security administrative departments, and the scope of inspection objects is designated medical insurance institutions, medical insurance handling institutions, etc.
, and at the same time, multiple departments may be combined or third-party institutions may be hired to carry out flight inspections
.
Chapter II Initiation, clarifying the circumstances of the initiation of the flight inspection, the composition of personnel, and other content
.
It is stipulated that the flight inspection team shall be composed of law enforcement personnel and other personnel familiar with relevant specialties, clarifying the "double random, one public" inspection mechanism and the form
of surprise inspection for situations such as reporting and complaints, intelligent surveillance, and media exposure.
Chapter III Inspections clarifies the law enforcement procedures for flight
inspections.
It is stipulated that inspectors shall conduct investigations and collect evidence in strict accordance with the relevant provisions of administrative punishment procedures, and that relevant individuals have the obligation to cooperate with the investigation, and the subject of inspection has the right to
make statements and defenses.
Chapter IV Handling clarifies the follow-up handling
of flight inspections.
It is stipulated that after the completion of the inspection, suspected violations of laws and regulations shall be handled separately in accordance with laws and regulations, clarifying the circumstances of the connection between the handling of agreements and administrative punishments, the circumstances of the connection between discipline, and the procedures
for "looking back" of flight inspections.
Chapter V Supplementary Provisions specify the departments responsible for the interpretation of the Measures and the time for
their implementation.
In recent years, the state has intensively promoted the special rectification
of insurance fraud.
In order to ensure that the people's "life-saving money" does not become "Tang monk meat" to be defrauded, the National Health Insurance Administration conducts multiple rounds of medical insurance flight inspections
every year.
According to statistics from the National Health Insurance Administration, from 2018 to 2021, through the special inspection of the supervision of the medical insurance fund and the daily verification of the handling institutions, a total of 2.
4 million designated medical institutions were inspected nationwide, 1.
15 million were processed, and a total of 58.
3 billion yuan of medical insurance funds were recovered.
By the end of 2021, the National Health Insurance Administration had carried out 160 sets of flight inspections, inspected 336 designated medical institutions, and found more than 3.
33 billion yuan
of suspected illegal funds.
Among them, problems such as excessive medical treatment, abuse of medical insurance funds, and fraud and insurance fraud have become the focus of
flight inspection.
In response to the above issues, the Draft not only clarifies the definition, principles, participation mechanism and other basic contents
of flight inspection.
At the same time, the "double random, one public" inspection mechanism and the form
of surprise inspection for situations such as reporting and complaints, intelligent monitoring, and media exposure are clarified.
Require that inspectors conduct investigations and collect evidence in strict accordance with the relevant provisions of administrative punishment procedures, that relevant individuals have the obligation to cooperate with the investigation, and that the subject of inspection has the right to
make statements and defenses.
In addition, the Draft also clearly stipulates that suspected violations of laws and regulations should be dealt with separately in accordance with laws and regulations after the completion of inspections, and clarifies the circumstances of the connection between agreement handling and administrative punishment, the connection between discipline, and the procedures
for "looking back" for flight inspections.
"Zero tolerance" for irrational use of drugs and devices
Legal compliance is a top priority
At present, the national medical insurance flight inspection is still continuing
.
In July this year, the "2022 Medical Security Fund Flight Inspection Work Plan" was officially issued, which set the focus of this year's medical insurance flight inspection as medical service behaviors and medical expenses
included in the scope of payment by the medical security fund in the fields of hemodialysis and high-value medical consumables (orthopedics, cardiology).
。
In fact, in the previous medical insurance flight inspection and illegal exposure cases, orthopedics, cardiology, hemodialysis, oncology and other fields, due to the large base of potential population, long and frequent diagnosis and treatment/rehabilitation cycles, or high medical insurance reimbursement ratio and amount, coupled with the complexity and uncertainty of medical behavior, violations of laws and regulations are extremely hidden, which can be said to be the "hardest hit area" where problems are concentrated:
In January 2021, Internet supervision information on the Chinese government website showed that Xi'an citizens had previously reported that the Third Affiliated Hospital of Xi'an Medical College (formerly Shaanxi Friendship Hospital) had defrauded the national medical insurance fund during hemodialysis examinations, and it was confirmed that the hospital had recorded more diagnosis and treatment and consumables items in hemodialysis for about two and a half years, and included outpatient dialysis expenses in the cost of hospitalization, involving a violation amount of 3.
0221 million yuan
。
In March 2021, the Nanjing Municipal Medical Insurance Bureau confirmed that two cardiologists in Nanjing Pukou District Central Hospital had used medical insurance funds in violation of regulations, such as unreasonable diagnosis and treatment, unreasonable drug use, etc.
, abused "outpatient chronic disease medical insurance reimbursement" to prescribe auxiliary drugs, and overprescribed drugs and other illegal use of medical insurance funds of 400,000 yuan
.
In August 2021, the orthopedic "sleeve" insurance fraud incident of the Sixth Hospital of Zhengzhou, Henan Province attracted widespread attention
.
At that time, the insurance fraud of the Sixth Hospital of Zhengzhou can be simply summarized as "shoddy charging": in the operation, the use of lower-priced medical consumables to replace similar higher-priced medical consumables and implant them into the patient's body
.
This behavior not only defrauds the medical insurance fund, but also makes patients spend money unjustly, and may cause medical risks
.
The above situation has obviously received great attention
from the medical insurance regulatory authorities.
Industry experts pointed out that problems such as excessive diagnosis and treatment, decomposition and hospitalization, and split/duplicate charges in large public medical institutions have not been eliminated, empty beds, false treatment, and over/excessive medication in primary medical institutions are widespread, and the problems of internal and external collusion between designated medical institutions and suppliers, and unreasonable use of drugs and equipment joint insurance fraud are prominent; These problems will be hidden in the big data information of the new round of flight inspections
.
The relevant person in charge of the National Health Insurance Administration previously publicly stated that the medical insurance department will seriously investigate and deal with insurance fraud with a "zero tolerance" attitude, and in accordance with relevant laws and regulations, the designated medical institutions involved in the case will not only impose administrative fines, but also suspend and terminate the medical insurance service agreement; Where crimes or other related issues are involved, they shall also be transferred to the judicial, discipline inspection and supervision, health and other departments
.
It is not difficult to see that the national level has made important arrangements for fund supervision on many occasions, clearly requiring strengthening the supervision of the use of medical insurance funds, and unswervingly cracking down on fraud and insurance fraud
.
With the deepening of medical insurance supervision, the use of medical insurance funds will be more transparent and standardized, whether it is medical institutions or pharmaceutical device companies, they must abandon the fluke mentality and keep the bottom line
of legal compliance.
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