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In order to implement the relevant requirements of the Guiding Opinions of the General Office of the State Council on Promoting the Reform of the Regulatory System of Medical Security Funds (Guo Ban Fa [2020] No.
20) and standardize the flight inspection of medical security funds, in accordance with the Social Insurance Law of the People's Republic of China, the Regulations on the Supervision and Administration of the Use of Medical Security Funds and other relevant laws and regulations, the National Medical Security Administration has studied and drafted the Interim Measures for the Management of Flight Inspection of Medical Security Funds (Draft for Comments
).
In order to further promote scientific, democratic, and law-based legislation, and improve the quality of legislation, we are now open to the public again for comments
.
Feedback from the public is available via email or written letter until 23 December 2022
.
Email: gcfgysc@nhsa.
gov.
cn
Mailing address: Department of Planning, Finance and Regulations, National Medical Security Administration, No.
2 Yuetan North Small Street, Xicheng District, Beijing 100830
National Health Security Administration
November 24, 2022
Interim Measures for the Administration of Flight Inspection of the Medical Security Fund
(Draft for solicitation of comments)
Chapter I General Provisions
Article 1: These Measures
are formulated in accordance with the "Social Insurance Law of the People's Republic of China", the "Regulations on the Supervision and Administration of the Use of Medical Security Fund" and other relevant laws and regulations, so as to strengthen the supervision and inspection of medical security funds and standardize the work of flight inspections.
Article 2: "Medical security fund flight inspections" (hereinafter referred to as "flight inspections") as used in these Measures refers to on-site supervision and inspections
organized and carried out by the national and provincial medical security administrative departments without prior notice to designated medical institutions, medical insurance handling institutions, other institutions undertaking medical insurance business, and other inspected objects.
Article 3: Flight inspections shall follow the principles of
seeking truth from facts, fairness and civility, and lawful procedures.
Article 4 The State administrative department for medical security is responsible for organizing and carrying out nationwide flight inspections
.
The provincial-level medical security administrative department shall be responsible for organizing and implementing flight inspections within their respective administrative areas
.
Inter-provincial joint and cross-flight inspections carried out by provincial-level medical security administrative departments shall be filed with the national medical security administrative departments before they are initiated
.
Article 5: Administrative departments for medical security shall establish communication mechanisms with relevant departments such as finance, health, market supervision, and traditional Chinese medicine, strengthen coordination and cooperation, and may cooperate with relevant departments to carry out flight inspections
when necessary.
The administrative department of medical security may hire qualified third-party institutions and professionals such as information technology service institutions, accounting firms, and commercial insurance institutions to assist in carrying out flight inspections
.
Article 6: Administrative departments for medical security shall strengthen the capacity building of flight inspections, and in accordance with relevant national provisions, allocate necessary inspection equipment and law enforcement evidence collection equipment for flight inspections, and increase the quality and efficiency
of flight inspections.
Article 7: Administrative departments for medical security shall accept supervision
of flight inspection work by all sectors of society.
Article 8 Personnel participating in flight inspections shall abide by laws and regulations, and strictly implement provisions on
confidentiality, recusal, and clean government.
Chapter II: Initiation
Article 9: In any of the following circumstances, the administrative department for medical security may initiate a flight inspection:
(1) The annual work plan is arranged;
(2) Reporting and complaint leads reflecting possible major security risks to the medical security fund;
(3) Where intelligent monitoring of medical security or big data screening suggests that the medical security fund may have major security risks;
(4) News media exposure, causing a major social impact;
(5) Other circumstances
where it is necessary to carry out flight inspections.
Article 10: In principle, the administrative departments for medical security shall adopt the method of "double random, one public" to organize and carry out flight inspections
arranged in the annual work plan.
In the circumstances provided for in Items 2 to 5 of Article 9 of these Measures, inspection work
may be carried out directly.
Article 11: Administrative departments for medical security are to establish a database of inspected targets, inspectors, and experts, and implement dynamic management
.
Article 12: The administrative departments for medical security organizing flight inspections shall make overall arrangements, do a good job of operational guidance and work guarantees, and dispatch flight inspection teams to carry out on-site inspections
.
The flight inspection team shall be composed of
medical security administrative law enforcement personnel and other personnel familiar with medical insurance, medical treatment, medicine, finance, information and other related majors.
Article 13: The administrative departments for medical security in the inspected localities shall cooperate in completing work related to flight inspections, promptly providing true, complete, and accurate policy documents, data information, and other relevant materials, and may dispatch administrative law enforcement and medical insurance auditing personnel to cooperate with on-site inspection efforts
as needed for inspections.
Chapter III: Inspection
Article 14: Flight inspection teams shall formulate specific implementation plans for flight inspections, clarifying inspection time, methods, procedures, priorities, standards, and methods for determining the objects to be inspected, actively studying and judging risks, and proposing prevention and control plans
as appropriate.
The implementation plan shall be implemented
after the approval of the medical security administrative department that organizes the flight inspection.
Article 15: After the flight inspection team arrives at the inspection site, it shall present the law enforcement certificate and relevant work certificate to the subject of inspection and serve the inspection notice, informing them of their rights and obligations
.
Article 16: The subject of inspection shall cooperate with the flight inspection work, clarify the person in charge of the site, promptly provide true, valid and complete documents, records, bills, vouchers, data, medical records and other relevant materials, truthfully answer the inquiries of the flight inspection team, and explain the suspicious data and relevant problems, and provide supporting materials
.
When necessary, the flight inspection team may question other persons and individuals related to the inspection matters and require them to explain the issues related to the inspection matters and provide relevant supporting materials
.
Relevant individuals shall cooperate
.
Article 17: On-site inspections shall involve at least two inspectors holding law enforcement identification
.
On-site inspections shall be made of written or audio-visual records, and the records shall be timely, accurate, complete, and effective, objectively and truthfully reflecting the on-site inspection situation
.
On-site inspections shall make on-site records, which are to be confirmed by the parties or relevant personnel by means such as signing or sealing them page by page
.
Where relevant personnel are questioned, the inspectors shall make a record of the questioning, and sign or stamp it page by page for confirmation
by the subject of questioning.
Article 18: Before the on-site inspection concludes an inspection, the flight inspection team shall give feedback to the inspected object on the relevant circumstances
of the inspection.
Where the subject of inspection has objections, it may make statements and defenses, and supplement relevant materials
.
The flight inspection team shall truthfully record, carefully review, fully study and judge, make collective decisions, and properly handle
disputed issues.
Article 19: Where the flight inspection team does not cooperate with the inspection, fails to truthfully provide relevant materials and information, or refuses to accept the inspection conclusion without legitimate reasons, it shall truthfully record it and promptly transfer it to the administrative department for medical security or other competent departments in the area being inspected for disposal
in accordance with laws and regulations.
Article 20: Where on-site inspections require an increase in inspection strength or an extension of inspection time, or where it is necessary to suspend or cancel an inspection due to special circumstances, the flight inspection team shall report to the medical security administrative department organizing the flight inspection for approval
.
Article 21: At the end of the on-site inspection, the flight inspection team shall fully communicate with the medical security administrative department of the place being inspected on matters such as whether the facts of the problems discovered during the inspection are clear, whether the evidence is sufficient, and whether the qualitative and quantitative problems are accurate, and use relevant laws and regulations and the medical security policies of the state and the coordinated area where the subject of the inspection is located as the basis
for determining violations of laws and regulations.
Major problems in flight inspections shall be promptly reported by the flight inspection team to the medical security administrative department organizing the flight inspection
.
Article 22 The flight inspection team shall, at the end of the flight inspection, form a written flight inspection report, report it to the medical security administrative department that organized the flight inspection, give feedback to the inspected object, and hand over the relevant materials
of the flight inspection to the medical security administrative department of the place being inspected.
Chapter IV: Handling
Article 23: The administrative department for medical security in the place being inspected shall, within 30 working days of receiving written feedback and handover materials, report the handling progress and rectification plan to the administrative department for medical security organizing the flight inspection, and submit a written report
within 5 working days after the completion of processing.
Where there is a significant discrepancy between the handling results of the medical security administrative department of the place being inspected and the results of the transferred examination, a written explanation
shall be given.
Article 24: The administrative department for medical security in the place being inspected shall require the subject of inspection to promptly rectify the problems discovered during the inspection, and handle suspected violations of laws and regulations in the feedback in accordance with laws and regulations:
(1) Violations of the medical insurance service agreement shall be handled by the medical insurance handling institution in accordance with the agreement;
(2) Lawfully give administrative punishments for unlawful conduct that truly warrants administrative punishments;
(3) Suspected violations of discipline, violations of law in public office, or crimes committed while in public officeclues of problems shall be transferred to discipline inspection and supervision organs in accordance with regulations;
(4) Where suspected violations of relevant laws, regulations, or rules should be handled by other departments, transfer them to the corresponding departments for handling;
(5) Other situations that need to be handled are to be handled
in accordance with provisions.
Article 25: The administrative departments for medical security organizing flight inspections shall include the results of the flight inspections in the comprehensive evaluation system for the work of the administrative departments for medical security in the place being inspected, supervise the handling of the results of the flight inspections, and organize forces to carry out the "review"
of the flight inspections in a timely manner.
Article 26: In response to regional, common, or long-standing, or prominent problems discovered during flight inspections, the administrative departments for medical security organizing the flight inspections may interview the targets of the inspection and the responsible persons of
the relevant medical security departments.
The subject of the interview shall propose corrective measures and report the rectification situation
within 15 working days.
Article 27 In any of the following circumstances, personnel participating in flight inspections shall be sanctioned
by the relevant departments in accordance with law and discipline in accordance with their management authority 。 Where a crime is suspected, it shall be transferred to the judicial organs for handling in accordance with law:
(1) Violating the spirit of the eight central provisions and their implementation rules;
(2) Leaking circumstances related to flight inspections, informant information, and information of the inspected target, or commercial secrets;
(3) Using materials obtained or known through inspections for purposes other than supervision and management;
(4) Having relatives, economic interests, or other interests with the subject of inspection or relevant personnel, and not carrying out requests for recusal;
(5) There are other violations of laws and regulations or violations of
discipline.
Where the irregular conduct of the personnel participating in the flight inspection causes a negative impact, the administrative department for medical security organizing the flight inspection shall notify
it within a certain scope.
Article 28: When necessary, the medical security administrative departments organizing flight inspections may report
the results of the flight inspections to the relevant departments of finance, health, market supervision, traditional Chinese medicine and other relevant departments at the same level.
Article 29: Administrative departments for medical security organizing flight inspections shall issue annual flight inspection announcements to expose typical cases
.
Chapter V Supplementary Provisions
Article 30: For the purposes of these Measures, the medical security administrative department of the place being inspected refers to the medical security administrative department
at the next level of the medical security administrative department that organizes the flight inspection.
Article 31: The National Medical Security Administration is responsible for the interpretation
of these Measures.
Article 32 These Measures shall be implemented
as of the beginning of this year.
The Regulations on Flight Inspection of Medical Security Fund Supervision (Medical Insurance Office Fa [2019] No.
21) are abolished
at the same time.
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