The Medical Insurance Bureau has issued a document that there are five types of situations that can initiate unannounced inspections!

On December 1, the National Medical Security Administration issued a public comment on the "Administrative Measures for Medical Security Fund Unannounced Inspection (Draft for Comment)".
The deadline for feedback is December 14, 2021
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After the implementation of these Measures, the "Regulations for Unannounced Inspection of Medical Security Fund Supervision" (Medical Insurance Office Fa [2019] No.
21) shall be repealed at the same time
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The announcement pointed out that this move implements the relevant requirements of the "Guiding Opinions of the General Office of the State Council on Promoting the Reform of the Medical Security Fund Supervision System" (Guobanfa [2020] No.
20), and regulates the unannounced inspection of medical security funds
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The "Draft for Comments" pointed out that the medical security fund unannounced inspection (hereinafter referred to as unannounced inspection) refers to the implementation of the national and provincial medical security administrative departments.
On-site supervision and inspection that the inspection object does not notify in advance
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And it is clear that the medical security administrative department can initiate unannounced inspections under one of the following circumstances: (1) The annual work plan is arranged; (2) The clues of the report and complaint reflect the possible major safety risks of the medical security fund; (3) Medical security Intelligent monitoring indicates that the medical security fund may have a major safety risk; (4) Exposure by the news media, causing a major social impact; (5) Other circumstances that require unannounced inspections
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At the same time, it is pointed out that the medical security administrative department adopts a "double random, one open" method to organize and carry out the unannounced inspections arranged in the annual work plan
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For reports and complaints, intelligent monitoring, news media exposure, etc.
that may cause major fund security risks or major social impacts, as well as the need for confidentiality, inspections can be carried out directly
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Those who participate in unannounced inspections should abide by laws and regulations, and strictly enforce disciplinary regulations such as confidentiality, avoidance, and integrity
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In any of the following circumstances, the relevant departments shall impose sanctions in accordance with discipline and law in accordance with the management authority
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Those suspected of committing crimes shall be transferred to judicial organs for handling in accordance with the law
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Including: leaking information about unannounced inspections, informant information, information of the inspected object, and trade secrets, or using materials and related information obtained or learned from inspections for other purposes other than supervision and management; having a relationship with the inspected object or related personnel Relatives, economic interests, and other interests, and various situations where the avoidance requirement is not implemented
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If the irregular behavior of the personnel participating in the unannounced inspection causes adverse effects, the medical security administrative department that organizes the unannounced inspection shall notify it within a certain range
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Attachment: Medical Security Fund Unannounced Inspection Management Measures (Draft for Soliciting Comments) Chapter 1 General Provisions Article 1 In order to strengthen the supervision and inspection of the medical security fund and standardize the unannounced inspection work, in accordance with the "Social Insurance Law of the People's Republic of China" and the "Regulations on the Supervision and Administration of the Use of Medical Security Funds" "Guiding Opinions of the General Office of the State Council on Promoting the Reform of the Medical Security Fund Supervision System" and other relevant laws and regulations, formulate these measures
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Article 2 The unannounced medical security fund inspections (hereinafter referred to as unannounced inspections) referred to in these Measures refer to the implementation of the medical security administrative departments at the national and provincial levels, to designated medical institutions, medical insurance agencies, and other institutions that undertake medical insurance business.
On-site supervision and inspection by the inspected object without prior notice
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Article 3 Unannounced inspections shall follow the principles of laws and regulations, seeking truth from facts, fairness and civilization, and rigorous procedures
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Article 4 The national medical security administrative department is responsible for organizing and implementing unannounced inspections nationwide
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Provincial medical security administrative departments are responsible for organizing and implementing unannounced inspections within their administrative areas
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Joint and cross unannounced inspections carried out by the provincial medical security administrative department shall be filed with the national medical security administrative department in advance
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Article 5 The medical security administrative department may invite relevant departments of health, traditional Chinese medicine, finance and other related departments to jointly conduct unannounced inspections, and may also hire qualified information technology service organizations, accounting firms, commercial insurance institutions and other third-party organizations and professionals to assist.
Carry out unannounced inspections
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Article 6 The medical security administrative department shall strengthen the standardization and capacity building of unannounced inspections, and in accordance with relevant national regulations, allocate necessary inspection equipment and law enforcement evidence-collecting equipment for unannounced inspections to improve the efficiency of unannounced inspections
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Article 7 The medical security administrative department shall actively accept the participation of news media and other social parties in the supervision of unannounced inspections
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Article 8 Personnel participating in unannounced inspections shall abide by laws and regulations, and strictly enforce disciplinary regulations such as confidentiality, avoidance, and integrity
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Chapter 2 Initiation Article 9 The medical security administrative department may initiate unannounced inspections under any of the following circumstances: (1) The annual work plan is arranged; (2) The clues of the report and complaint indicate that the medical security fund may have a major safety risk; (3) Medical security intelligent monitoring indicates that the medical security fund may have a major safety risk; (4) Exposure by the news media, causing significant social impact; (5) Other circumstances that require unannounced inspections
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Article 10 The medical security administrative department shall organize and carry out the unannounced inspections arranged in the annual work plan by means of "double random, one open"
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For reports and complaints, intelligent monitoring, news media exposure, etc.
that may cause major fund security risks or major social impacts, as well as the need for confidentiality, inspections can be carried out directly
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Article 11 The medical security administrative department establishes a database of inspected objects, flight inspection team leaders, inspectors, and experts, and implements dynamic management based on the inspected objects, personnel changes, and personnel evaluations
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The medical security administrative department shall determine the list of inspected objects, unannounced inspection team leaders, inspectors, and experts so that traces can be traced throughout the entire process and responsibilities can be traced
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Article 12 The medical security administrative department that organizes unannounced inspections shall make overall arrangements, do a good job guarantee, and dispatch unannounced inspection teams to carry out on-site inspections
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The unannounced 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 professions who have obtained authorization for this inspection.

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Article 13 The medical security administrative department of the inspected province (city) shall cooperate with the unannounced inspections, provide timely, true, complete and accurate policy documents, data information and other relevant materials, and send administrative law enforcement personnel to participate in the on-site inspections
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Chapter III Inspection Article 14 The flight inspection team shall formulate a specific implementation plan for the flight inspection, clarify the inspection focus, methods, procedures, etc.
, actively study and judge risks, and propose prevention and control plans as appropriate
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The implementation plan is submitted to the medical security administrative department that organizes the unannounced inspection before being implemented
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Article 15 After the flight inspection team arrives at the inspection site, it shall show the relevant work certificates and serve the inspection notice to the inspected object, informing them of their rights and due obligations
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Article 16 The subject to be inspected shall, in accordance with the requirements of the flight inspection team, clarify the person in charge, cooperate with the on-site inspection work, timely provide true, valid and complete documents, records, bills, vouchers, data, medical records and other relevant materials, and truthfully answer the flight Check the group's query
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Article 17 At least two inspectors should participate in the on-site inspection
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On-site inspections should be well documented or recorded in audio and video.
The records should be timely, accurate, complete, and effective, and objectively and truly reflect on-site inspections
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On-site inspections shall be made on-site transcripts, and confirmed by the parties or related personnel by means of signatures or seals page by page
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When questioning the relevant personnel, the inspector shall make a record of the question and sign it page by page or confirm it by fingerprint
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If the on-site inspection finds that the inspected object is suspected of violating the relevant laws, regulations, and rules of medical security, investigation and evidence collection shall be conducted in strict accordance with the relevant provisions of the medical security administrative punishment procedure
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Article 18 Before an on-site inspection makes an inspection conclusion, the flight inspection team shall feed back the inspection information to the inspected object
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If the inspected object has objections, an explanation may be made and relevant materials may be supplemented
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The flight inspection team shall truthfully record, carefully review, and fully study and judge
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Article 19 If the unannounced inspection team fails to cooperate with the inspection and fails to provide relevant materials and information truthfully, it shall truthfully record and transfer it to the medical security administrative department of the inspected province (city) for disposal in accordance with laws and regulations
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Article 20 If an on-site inspection needs to increase the inspection force, extend the inspection time, or suspend or cancel the inspection due to special circumstances, the flight inspection team shall report to the medical security administrative department that organizes the flight inspection for approval
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Article 21 At the end of the on-site inspection, the unannounced inspection team shall fully communicate with the provincial (municipal) medical security administrative department of the inspected province (municipal) on whether the facts found in the inspection are clear, whether the evidence is sufficient, whether qualitative and quantitative are accurate, and other relevant matters
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The unannounced inspection team shall adopt the reasonable opinions put forward by the medical security administrative department of the inspected province (city), form objective and fair written feedback opinions, and hand over relevant documents, data and evidence for unannounced inspections
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Article 22 The unannounced inspection team shall form a written unannounced inspection report at the end of the unannounced inspection, and submit it to the medical security administrative department that organized the unannounced inspection for the record
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Chapter IV Handling Article 23 The medical security administrative department of the inspected province (city) shall, within 30 working days of receiving the written feedback and the handover of the materials, report the processing result and the rectification plan to the medical security administration that organized the unannounced inspection Department, and submit a final report after processing
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If the processing result of the medical security administrative department of the inspected province (city) is significantly different from the transferred inspection result, a written explanation shall be provided
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Article 24 The medical security administrative department of the inspected province (city) shall deal with the reported suspected violations of laws and regulations in accordance with the law and regulations in accordance with the authority and procedures: (1) For violations of the medical insurance service agreement, the medical insurance agency shall follow The agreement stipulates to deal with it; (2) Administrative penalties will be imposed in accordance with the law for violations of relevant laws, regulations, and rules on medical security; (3) Party members, supervision targets, or designated medical institutions, medical insurance administrative departments, medical insurance agencies, etc.
, are found Responsible comrades of the unit are transferred to the disciplinary inspection and supervision agency for information related to suspected violations of discipline or duty violations or crimes; (4) For suspected violations of relevant laws, regulations, and rules, which should be handled by other departments, they shall be transferred to the corresponding departments for handling; (5) Others Circumstances that need to be dealt with shall be dealt with in accordance with the corresponding regulations
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Article 25 The medical security administrative department that organizes unannounced inspections shall incorporate the unannounced inspection results into the performance evaluation system for the work of the province (municipal) medical security department under inspection, supervise the handling of unannounced inspection results, and conduct follow-up investigations and rectifications.
In case of ineffectiveness, we can organize the force to carry out unannounced inspections "look back" in due course
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Article 26 Regarding the regional, universal, or long-term, prominent problems found during unannounced inspections, the medical security administrative department that organizes unannounced inspections may interview the person in charge of the medical security department where the inspected object is located
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The medical security department interviewed shall propose rectification measures and report the rectification situation within 15 working days
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Article 27: Persons participating in unannounced inspections in any of the following circumstances shall be punished by relevant departments in accordance with disciplines and laws in accordance with their management authority
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Those suspected of committing crimes shall be transferred to judicial organs for handling in accordance with the law
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(1) Refusing to implement or deliberately violating the party and the state's guidelines, policies, and decision-making arrangements, or words and deeds that cause political influence and harm the interests of the party and the state; (2) Violating the spirit of the eight central regulations and their implementation rules; (3) Leaking relevant information about unannounced inspections, informant information, information of the inspected object, and trade secrets, or using materials and related information obtained or learned during inspections for purposes other than supervision and management; Relevant persons have relatives, economic interests, and other interests, and fail to implement the recusal requirements; (5) Have other violations of laws, regulations, and disciplines
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If the irregular behavior of the personnel participating in the unannounced inspection causes adverse effects, the medical security administrative department that organizes the unannounced inspection shall notify it within a certain range
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Article 28 The medical security administrative department that organizes the unannounced inspection shall promptly report the relevant results of the unannounced inspection to the relevant departments of health, traditional Chinese medicine, and finance at the same level
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Article 29 The medical security administrative department that organizes unannounced inspections shall disclose the results of unannounced inspections to the public in accordance with laws and regulations, and expose typical cases
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Chapter V Supplementary Provisions Article 30 The National Medical Security Administration is responsible for the interpretation of these measures
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Article 31 These Measures shall be implemented from January 2021
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The Regulations for Unannounced Inspection of Medical Security Fund Supervision (Medical Insurance Office Fa [2019] No.
21) shall be repealed at the same time
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