The State Council re-issued a document on health insurance supervision to introduce a third-party policy tightening!

Health-care fund regulatory reform has been a "project" pushed by the National Health Insurance Administrationshortly after the establishment of the Health Insurance Administration, the National Health Insurance Administration launched a special campaign against fraudulent insurance, and is now working with the Ministry of Justice and other ministries to promote the regulation of health insurance fundsOn the night of July 9,, the General Office of the State Council issued the Guidance on Promoting the Reform of the System of Supervision system of The Medical Security Fund, which pointed out that the supervision system is not perfect, the incentive and restraint mechanism is not perfect and other factors, the use of medical insurance funds is not efficient, the problem of fraud and insurance is frequent, and the supervision situation of the fund is more serioustherefore, in order to comprehensively improve the ability of medical insurance governance, deeply purify the operating environment of the system, strictly observe the fund security red line, with the consent of the State Council, on the promotion of the reform of the system of supervision of the medical insurance fund put forward a number of viewsthe regulation of health-care funds, both central and local policies have been introducedbut this time the State Council's guidance on some of the content still controversial provisionsfirst,, in the disciplinary system of medical institutions, the document pointed out that the establishment and improvement of fixed-point medical institutions dynamic management and exit mechanismin fact, there are already policies and actions in the regulation of health-care funds introduced in the last two years, and there are precedents for implementationfor example, on May 29 this year, the Health Insurance Bureau of Huainan City, Anhui Province, dealt with the violation of the law by 18 pharmaceutical institutionsAccording to the Huainan Municipal Health Insurance Bureau, the violations involved in the local cancer hospital, Chinese hospitals, community health service centers, pharmacies and other institutions, involving the amount of violations of nearly 8 million yuan, of which Chaoyang Hospital and Xinhua Hospital, the highest amount of violations, reached 1.9926 million yuan, 1.9126 million yuanthe State Council in this document, the medical security departments in accordance with the law to increase administrative penalties"For designated pharmaceutical institutions that have been verified by the medical security department and whose fraud and insurance cases are particularly serious, the health and health and drug regulatory departments shall, in accordance with the law, impose penalties such as suspension of business and rectification, revocation of qualifications for practice (operation) and restrictions on their practice, and enhance the deterrent effect of punishment"But it's worth noting that only some of the hospitals in this penalty have been suspended for 1-6 months, and some relatively large general hospitals have not been suspended from health-care billing services."clearly, for some places, the suspension of medical insurance settlement in large general hospitals will inevitably have a significant impact on the treatment of local patients, so the difficulties in implementing dynamic management and exit mechanisms for medical institutions remain enormoussecondly, the guidance also proposes to extend the supervision object from medical institutions to medical personnel, shift the supervision focus from medical expense control to double control of medical expenses and medical service performance, introduce and implement the medical and health industry standards, gradually carry out clinical path management, improve and implement the clinical pharmacist system, prescription evaluation system, strengthen clinical application and evaluation and other standards of standard application a previous consultation meeting between the Ministry of Justice and the Health Insurance Administration, some experts raised the question of whether doctors and pharmacists who violate the regulations could take more severe measures until they restrict medical services and revoke their qualifications divided on the scene, the opposition side believes that this is not within the purview of the Health Insurance Board, hospitals, doctors competent departments for the health sector, and revocation of the practice of the law may conflict with the upper law, while the support side believes that "their own children in charge" may lead to poor governance on this issue, some experts suggest that through the information disclosure mechanism to form self-restraint, the hospital for the use of health insurance funds, the effect of a certain degree of regular publicity, doctors and pharmacists of violations, can be included in the credit evaluation system, thereby restricting the relevant behavior experts at the meeting suggested that the violation of regulations, fraud of health insurance funds should also be publicized, negative information publicity helps to form a stronger binding force the State Council this document to implement the above-mentioned measures, pointed out that fraud and fraud serious circumstances of the fixed-point medical institutions and individuals, included in the list of joint disciplinary objects of breach of trust, the implementation of joint disciplinary measures In addition, , for some gaps and ambiguities in the law, the document points out that the Legislative Interpretation of the Standing Committee of the National People's Congress on fraud and insurance fraud should be strictly implemented, and cases of suspected crimes should be transferred to judicial organs for criminal responsibility in accordance with the law; and for the rights and responsibilities of the health insurance and health departments, the above-mentioned documents are also clear, medical insurance is responsible for regulating medical service behavior and medical expenses, regulating the operation of medical insurance, according to law to investigate and punish violations of laws and regulations in the field of medical security, while the health and health departments are responsible for strengthening the supervision of medical institutions and medical services, regulating medical institutions and their medical personnel medical services and regulatory means, the document calls for the establishment of an information disclosure system, and the operating agencies regularly announce to the community the fund's income and expenditure, balance and income, and accept social supervision establish a system of social supervisors of medical insurance funds, employ deputies to the National People's Congress, cppcc members, representatives of the masses and the media as social supervisors, and third-party forces such as information technology service institutions, accounting firms and commercial insurance institutions will also participate in the supervision of the health insurance fund, and regularly engage third-party organizations to assess the risks of internal control of the operating institutions and strengthen internal control .