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On November 25, the National Health Insurance Administration and the Ministry of Finance jointly formulated the Measures for Reporting Incentives for the Illegal Use of Medical Security Funds (hereinafter referred to as the "Incentive Measures"), which will be officially implemented
on January 1, 2023.
According to the Reward Measures, whistleblowers who meet the relevant conditions for reporting can receive a reward of up to 200,000 yuan
.
This is a significant increase
from the previous reward of 100,000 yuan.
Following the release of the "Interim Measures for the Administration of Flight Inspection of the Medical Security Fund (Draft for Comments)" on the 24th, the National Health Insurance Administration once again issued the "Incentive Measures", sending a very strong regulatory signal
.
With the deepening of the "three-doctor linkage", the reform of review and approval, the adjustment of medical insurance payment, and the supervision of rational drug use have been gradually improved, and joint efforts have been made to ensure the safety of public drug use
.
In view of major violations of laws and regulations in the pharmaceutical field, rallying social forces and encouraging the public to report is undoubtedly an important measure
to promote social co-governance.
Bonuses can be adjusted up and paid conveniently
Social forces are gathering again!
The Incentive Measures are amendments to the 2018 Interim Measures for Reporting Rewards for Fraudulent Acquisition of Medical Security Funds (hereinafter referred to as the "Incentive Measures"
).
As a supporting document of the Interim Measures for the Supervision and Management of the Use of Medical Security Funds, the Reward Measures contain 15 articles, which stipulate the purpose basis and scope of application of the whistleblowing reward system, as well as the principles, conditions, standards, issuance, receipt, redemption and recovery of rewards, and also fully reflect the considerations
in deepening the reward reporting system and encouraging the public to participate in supervision.
It is clearly mentioned that all reports of illegal use of medical insurance funds will be included in the scope of rewards, and combined with the actual situation in various places, it is stipulated that a one-time reward
will be given to whistleblowers according to a certain proportion of the value of the case.
At the same time, the upper limit of the reward amount was raised from 100,000 yuan to 200,000 yuan, and a minimum minimum reward amount of 200 yuan was set to give full play to the role of rewards and incentives, and actively encourage and guide the public to participate in social supervision
。
In addition, in order to cooperate with the promulgation and implementation of the "Reward Measures", the National Health Insurance Administration has specially developed and used a reporting and complaint management system on the national medical security information platform, striving to carry out the whole process, whole chain and all-round accurate management of reporting leads in various channels.
On the other hand, timely supervise local medical insurance departments to issue reporting rewards on time and in full, and ensure that rewards must be awarded
.
At present, the system has been piloted in Hebei, Zhejiang and Jiangxi provinces, and will be promoted and used
nationwide when the conditions are ripe.
For a long time, the National Health Insurance Administration has always regarded maintaining the safety of medical insurance funds as its primary task, constantly exploring innovative fund supervision methods, and actively encouraging and supporting all sectors of society to participate in fund supervision
.
In November 2018, the National Health Insurance Administration and the Ministry of Finance jointly issued the original Incentive Measures, initially establishing a reward system for reporting fraud and defrauding the medical security fund, aiming to further mobilize social forces to participate in the supervision of violations of laws and regulations and jointly maintain the safety of
the medical insurance fund.
The original "Incentive Measures" played an important role
in mobilizing social forces to participate in fund supervision and maintaining the safety of medical insurance funds.
In April this year, the Tongji Hospital insurance fraud case shocked the industry
.
According to the National Health Insurance Administration, the incident was detected based on a whistleblower tip
.
There is no doubt that medical insurance supervision is based on reporting clues and cracking down on violations of laws and regulations, which is a measure
to optimize the industry ecology and improve the supervision of the whole chain.
At present, 31 provinces (autonomous regions and municipalities directly under the central government) and the Xinjiang Production and Construction Corps have established corresponding reporting reward systems, which has promoted the benign interaction between government supervision and social supervision, and created a good atmosphere
of social co-governance and sharing of fund supervision.
The general public's awareness of supervision has been continuously improved, and they have actively participated in the supervision of medical insurance funds, and the number of people reporting and rewarding, the amount of rewards issued, and the amount of violations investigated and dealt with have increased year by year, and the role of social supervision in combating fraud and insurance fraud has become increasingly significant
.
Medical insurance departments at all levels have successively rewarded more than 2,570 whistleblowers and issued nearly 5 million yuan in whistleblowing rewards, and Tianjin, Zhejiang, Guangxi and other three provinces (autonomous regions and municipalities) received a maximum reward of 100,000 yuan for a single person, and verified and recovered 158 million yuan
of medical insurance violations according to the relevant public reporting clues.
In fact, the compliance pressure in China's pharmaceutical industry has reached unprecedented levels
.
Whether it is for downstream medical institutions or upstream pharmaceutical companies, paying attention to the reporting of clues about violations of laws and regulations has become a starting point
for severely cracking down on commercial bribery.
"Flight inspection" and "reporting" multi-line attack
Violations of laws and regulations will not go unnoticed
For a long time, the illegal use of medical security funds has been frequent, seriously infringing on the legitimate rights and interests of the people, undermining the normal operation of medical insurance funds, and causing bad social impact
.
In November, the exposure desk of the National Health Insurance Administration released the fourth phase of typical cases
in 2022.
Up to now, the National Health Insurance Administration has exposed a total of 53 typical cases
in 2022.
Duplicate charges, over-standard charges, decomposition project charges, over-medical insurance limited payment scope settlement, serial replacement of medical treatment items and drug consumables invoicing.
.
.
The above-mentioned violations of laws and regulations by medical institutions have caused losses to the medical insurance fund, damaged the image of designated medical institutions, and had a negative impact
on society.
In April 2022, the Tianjin Municipal Medical Security Bureau found during a special inspection of the use of medical insurance funds by medical institutions that Tianjin Anjie Hospital Co.
, Ltd.
was suspected of using medical insurance funds
in violation of regulations.
After verification, the hospital had violations of laws and regulations, such as duplicate charges, serial exchange of diagnosis and treatment items, and inclusion of medical expenses that were not covered by the medical insurance fund into the settlement of the medical insurance fund, involving the illegal use of the medical insurance fund of 511,596.
55 yuan
.
In May 2021, the Haikou Municipal Medical Security Bureau of Hainan Province found during the daily supervision of the use of medical insurance funds that Haikou Maternal and Child Health Care Hospital was suspected of using medical insurance funds
in violation of regulations between June 2020 and April 2021.
After verification, the hospital had problems such as illegal collection of low-value medical consumables, inflated fees, excessive diagnosis and treatment projects, duplicate charges, and decomposition charges, involving a total of 2,178,461.
50 yuan
.
In June 2021, the Sichuan Provincial Medical Security Bureau inspected
the use of medical insurance funds of Suining Shehong Hospital of Traditional Chinese Medicine.
After verification, the hospital had violations of laws and regulations such as decomposition project charges, duplicate charges, and collusion of diagnosis and treatment items, involving the illegal use of medical insurance funds of 3,762,110.
71 yuan
.
.
.
.
.
.
.
Since the official implementation of the first regulatory regulation in the field of medical insurance "Regulations on the Supervision and Administration of the Use of Medical Security Fund" on May 1 last year, the National Health Commission, the National Health Insurance Administration, the State Food and Drug Administration and other relevant departments have continued to increase their supervision efforts, effectively deterring bribery, medical insurance fraud, sales with money and other violations of laws and regulations
.
The issuance of the "Incentive Measures" means that the supervision of medical insurance funds will be further strengthened by uniting the forces of the masses
.
From the industry's point of view, the measures taken by medical insurance regulators to combat insurance fraud will become normal and sustainable
.
The reform and improvement of the medical insurance system is an unstoppable trend, the pace of "three-doctor linkage" is accelerating, and value-added services such as pharmaceutical services and drug procurement (distribution, sales) will form a new interactive relationship
with medical insurance and hospitals (doctors) in the future.
Whether in or outside the hospital, returning to the core value of the medical service market and the original intention of the industry, actively controlling the unreasonable growth of medical expenses, strictly implementing medical insurance policies, and promoting the rational use of medical insurance funds, legal compliance is the best solution
for healthy development.
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