National Health Insurance Administration Releases Medical Insurance Management Efficiency Improvement Cases (Eighth Batch)

Innovation is the first driving force to lead development, and to promote the refined management of medical insurance, we must constantly adapt to the new environment, promote the application of new technologies, promote effective new methods, provide convenient and efficient medical security services for the people, and protect the people's "life-saving money"
.
The eighth batch of medical insurance management efficiency improvement cases are released, including Shanghai Jing'an's focus on "intelligent, convenient and humanized" to build a smart medical insurance service system, and Zhejiang Jinhua's "five rectification and one cleanup" to build a solid medical insurance fund security defense line
.

 

Office of the National Health Security Agency

 

October 12, 2022

 

Shanghai Jing'an focuses on "intelligent, convenient and humanized" to build a smart medical insurance service system

 

Shanghai Jing'an District actively explores innovative ways for the government to perform its duties digitally, leads the community affairs acceptance service centers in each street and town in the district, focuses on the problems that the people are anxious about, reengineering business processes, improving service capabilities through the application of the Internet, big data, cloud computing and other technologies, building an "intelligent, convenient and humanized" smart medical insurance service system, and continuously improving the people's sense of gain, happiness and security in medical insurance public services
.

 

First, focus on "intelligence", policies to find people, service delivery
.
The first is to actively explore a new model
of "free application and enjoyment".
Jing'an District has opened up data sharing channels for medical insurance, civil affairs, education, streets and towns, promoted the reengineering of the whole process of business, and realized the implementation of two "free and enjoy" service projects
: "medical expense subsidies for special groups" and "medical assistance services for people in difficulty".
Relying on the online service system, the competent departments automatically calculate data in accordance with policy algorithms and actively complete the push
of results.
The client does not need to make an application or provide documentary documents
.
A total of 87,000 cases have been handled, with an amount of more than 37 million yuan, realizing "zero application, zero materials, and zero running"
for the insured.
The second is to launch a new experience
of "smart butler".
Daning Road Street in Jing'an District explores and optimizes data application scenarios, innovatively launches the "Daning Easy to Ban" WeChat mini program, and handles "long-term care insurance registration" and other services online in the form of "one-to-one" video
by integrating audio and video, AI, 5G, IM and other technologies.
The system deeply analyzes user characteristics according to the consulting content, forms a personalized "one person, one file", judges the potential needs of the masses in advance, actively pushes exclusive personalized business handling notification services, and provides handling and online consultation paths
.
At the same time, relying on the "two-way express" platform, the paper materials and processing results
generated in the process of delivery are delivered.
The third is to promote the handling process to achieve "random inspection"
.
Based on the refined management and information integration of business processes, Baoshan Road Street in Jing'an District has launched a convenient query system of "check at will", which can understand the business process by scanning the exclusive QR code query port
.

 

Second, focus on "convenience", business sinking, cross-forward extension
.
The first is to vigorously promote "online office" and "palm office"
.
Expand the "one-network office" of public service matters in the region, and add 45 district-level high-frequency medical insurance public service projects, all of which can be handled
online on the "one-net-office" platform.
The second is to "run nearby"
high-frequency business.
Pengpu Town, Jing'an District, has set up an extension point for community affairs reception services in residential areas, where insured persons can handle high-frequency medical insurance services such as "long-term care insurance registration" and "replacement of medical records" nearby, and improve the community's "10-minute living circle" service
.
The third is the "same-day delivery"
of business materials.
Shimen 2nd Road Street, Jing'an District, has established a docking mechanism with logistics companies, and a special person is responsible for coordinating the "same-day delivery of medical records" business, setting up document exchange cabinets, and providing 24-hour self-service access services
such as office materials, receipts, and medical records.

 

Third, focus on "humanization", take the initiative to care, warm and intimate
.
The first is to carry out the "cloud handling"
of the end-of-term assessment of long-term care insurance for the elderly and disabled.
In response to the problem that the long-term care insurance services for the elderly and disabled cannot be evaluated and renewed in time under the situation of normalized epidemic prevention and control, the Jing'an District Medical Insurance Bureau has carried out the "cloud evaluation" mode of long-term care insurance in elderly care institutions, strengthened cooperation with elderly care institutions, and relied on the medical staff of elderly care institutions to do a good job in "cloud uploading" of elderly health management information and "cloud entrustment" of
family members 。 Carry out disability level assessment by video connection, upload the assessment data to the municipal medical insurance information platform in a timely manner, and inform the elderly or agents by telephone by the community affairs reception center, so as to achieve remote non-face-to-face, non-contact assessment, and uninterrupted
service.
The second is to bridge the "digital divide"
among the elderly.
Gonghe Xinlu Street in Jing'an District has set up a "learning corner" in the street service hall, playing an exclusive sitcom video to guide the elderly to understand and use the "one-net-office" platform
.
Arrange special personnel to carry out "online assistance" for the elderly, and provide residents in the jurisdiction with services such as "dispensing medicines on behalf of them and delivering them to their doors", effectively alleviating the needs
of the elderly such as difficulty in dispensing medicines.
The third is to weave a dense "security net"
for special groups.
Pengpu Xincun Street, Jing'an District, adopts "one case and one discussion" for the needs of some special groups, provides door-to-door services, etc.
, to ensure that "policies are matched in place and treatment is not leaked", so as to achieve warm services
.
District and street service halls are set up with green channels for special groups to provide services such as "assistant", "agency", "companion" and "priority"; Set up a special seating area, a mother and baby area, equipped with wheelchairs, reading glasses, love medical care kits, AED first aid equipment, etc.
, to provide temporary care services
.

 

Zhejiang Jinhua's "five rectifications and one cleanup" build a solid security defense line for medical insurance funds

 

Jinhua City, Zhejiang Province took the opportunity of building a national demonstration site for medical insurance intelligent monitoring, established a linkage supervision mechanism, paid attention to digital application, focused on carrying out special rectification in five areas: accidental injury, hemophilia, organ transplantation, rehabilitation, and genetic testing, cleaned up the problem of "ambiguous zone" existing in medical behavior, continuously extended the tentacles of medical insurance fund supervision, and effectively guarded the "life-saving money"
of the masses.
Since 2021, 192 designated medical institutions, 286 illegal insured persons have been handled, 77 people have been transferred to judicial organs, 45 cases have been filed by public security organs, and 116 million yuan
of medical insurance fund losses have been recovered.

 

First, pay attention to internal and external outreach, from a single supervision to the linkage of six departments
.
First, overall planning and sub-supervision
at the municipal level.
Establish a special class for the supervision of medical insurance funds, and build a management mechanism
that integrates the whole city, links up and down, and has a clear division of labor.
The Municipal Medical Insurance Bureau is responsible for formulating plans, organizing cross-inspections, and carrying out supervision and guidance; The county (city, district) medical insurance bureau uniformly participates in the city's flight inspection action and completes the self-selected action
.
The second is cross-departmental coordination and thorough investigation
.
The six departments of medical insurance, public security, health, market supervision, courts and procuratorates jointly issued the "Implementation Opinions on the Linkage Supervision of Jinhua Medical Security Fund Departments" and the "Jinhua Three-Year Action Plan for Jointly Cracking Down on Fraud and Fraud of Medical Security Fund", building linkage mechanisms
such as execution linkage, information sharing, joint meetings, and case consultations.
An interdepartmental special case liaison group has been established to specifically crack down on insurance fraud in the fields of hemophilia and organ transplantation, and 12 cases have been transferred to the public security, involving 280 criminal suspects
.
Third, third-party supervision cooperates with investigation
.
Integrate the existing regulatory forces of the municipal medical insurance system in advance, and at the same time establish a third-party supervision service center
composed of medical, information, legal and other professionals through the purchase of services.
Equipped with 50 professionals, it assists the medical insurance department in carrying out daily supervision and review, effectively solves the problem of insufficient regulatory strength, and assists in the recovery of more than 56 million yuan
of medical insurance funds.

 

Second, pay attention to precise force, from the point to break through to "surface into a net"
.
First, big data analysis provides clues
.
Taking the construction of the national medical insurance intelligent monitoring demonstration site as an opportunity, relying on the medical knowledge base and dynamic supervision rule database, intelligent monitoring and analysis of drug dosage, medical expenses and other information of all hemophilia patients and organ transplant patients in the city are carried out, focusing on the review of special disease outpatient and outsourced prescription settlement data to ensure that once there is an abnormal situation such as overdose and repeated dispensing, it is timely discovered and accurately identified
.
The second is to establish a full-coverage verification mechanism
.
In response to the frequent occurrence of cases of deliberately concealing third-party liability in the field of accidental injury to defraud medical insurance funds, hospital-based inspections, on-site inspections, door-to-door investigations, data sharing, etc.
, are used to carry out third-party verification of accidental injury medical insurance payments in the city to achieve full on-site coverage
.
Since 2021, a total of 68,100 accidental injury payment cases have been verified, and more than 7,000 suspicious cases have been found, with a verification and discovery rate of more than 10%.

At the same time, relying on suspicious data analyzed by big data in the fields of hemophilia and organ transplantation, offline whole-process verification is carried out to ensure that there are "no loopholes" in supervision and "no dead ends"
in inspection.
The third is to establish a self-examination and self-correction mechanism
.
In response to the chaos in the field of rehabilitation treatment, such as false memories and unreasonable diagnosis and treatment, a special governance plan is formulated, requiring all medical institutions involved in medical rehabilitation in the city to carry out self-examination and self-correction and rectification
.
At present, the self-inspection and self-correction rate of 147 medical institutions involved in rehabilitation treatment in the city has reached 100%, and the amount of self-inspection and self-correction is 3.
49 million yuan
.

 

Third, pay attention to consolidating the foundation and strengthening the foundation, and prevent and warn in advance from post-supervision to early warning
.
First, improve the management system in
key areas.
Focus on the diagnosis and treatment process and verification standards in specific fields, and successively issue system specifications such as medical insurance reimbursement for accidental injury cases, medical insurance payment for anti-tumor targeted drugs, and hemophilia medical services, so as to realize the professionalization, standardization and refinement of
fund supervision.
The second is to clarify the boundaries
of medical service payment.
In view of the problem of "ambiguous areas" that are not explicitly stipulated in medical insurance policy documents and are controversial in the implementation process, carry out a clean-up of the "ambiguous areas" of medical service behavior, clarify relevant regulations and standards, and make the "ambiguous areas" not ambiguous
.
The first batch of 16 medical service projects has been standardized and distributed to designated medical institutions, and the second batch of clean-up actions for 10 types of medical service projects such as rehabilitation have also been successfully completed
.
The growth rate of the overall cost of medical service projects related to medical institutions decreased from 42.
6% in 2020 to -0.
4% in 2021, effectively reducing the waste of
medical insurance funds.
The third is to promote the formation of a joint force
of social supervision.
Publish and issue detailed rules for the implementation of rewards for reporting insurance fraud, and unblock channels for
complaints and reports.
Establish a team of social supervisors, and select 160 people in the first batch of the city to form an interaction
between social supervision and government supervision.
Formulated the "Jinhua Urban DRGs Payment Industry Self-discipline and Mutual Review Work Plan", set up a self-discipline mutual review team led by three urban medical alliances in the urban area, and reviewed a total of 658 cases of violations, deducting 1720.
84 points, effectively strengthening industry self-discipline
.