Guarding the 'money bag' of medical insurance - release of the qualification management system for medical insurance payment
2024-10-08
The supervision of medical insurance funds is related to the "money bag" of ordinary people's medical treatment. The National Healthcare Security Administration, National Health Commission, and National Medical Products Administration recently jointly released the "Guiding Opinions on Establishing a Medical Insurance Payment Qualification Management System for Relevant Personnel in Designated Medical Institutions", which clearly requires the management of medical insurance payment qualifications. What is the medical insurance payment qualification management system? What role will it play in regulating the current medical insurance fund? Not long ago, the National Healthcare Security Administration held a press conference to provide relevant interpretations. At present, the regulatory situation of medical insurance funds remains severe and complex, and fraudulent and illegal activities such as insurance fraud still occur in the use of funds. Medical staff holding a prescription "pen" is an important force in maintaining the security of the medical insurance fund. Gu Rong, Director of the Fund Supervision Department of the National Medical Insurance Administration, stated that the medical insurance payment qualification management system starts from the key link of medical insurance payment under the framework of medical insurance agreement management, and implements a "driver's license style scoring" for relevant personnel of designated medical institutions. The guidance specifies that for responsible personnel of designated medical institutions who violate laws or service agreements, based on administrative penalties or agreement processing of the designated medical institutions, the department responsible for the processing shall determine the responsibility of the relevant personnel and score them according to the nature of their behavior and the degree of responsibility they bear. The scoring levels are divided into 1 to 3 points, 4 to 6 points, 7 to 9 points, and 10 to 12 points. Gu Rong introduced that those who score 9 points within a calendar year will have their medical insurance payment eligibility suspended for 1 to 6 months. Medical insurance fees incurred during the suspension period for providing services will not be settled (except for first aid and rescue). If the score reaches 12 points within a calendar year, the eligibility for medical insurance payment will be terminated, and the medical insurance fees incurred during the termination period will not be settled. Among them, those who have accumulated 12 points due to minor violations shall not be allowed to register and file again within one year from the date of termination; For those who accumulate 12 points at once, they are not allowed to register and file again within 3 years from the date of termination. The guidance requires that provincial medical security departments gradually include relevant responsible personnel in the scoring management within three years to ensure smooth implementation. Explore incorporating the management of medical insurance payment qualifications for relevant personnel into the medical insurance credit management system. Since the beginning of this year, the National Healthcare Security Administration has increased its efforts in flight inspections and reported multiple cases of suspected fraud and insurance fraud in multiple regions. Yan Qinghui, Deputy Director of the National Medical Insurance Administration, stated that in recent years, the supervision of medical insurance funds has been continuously strengthened. However, the illegal and irregular use of medical insurance funds by designated medical institutions is still repeatedly investigated and prohibited. The traditional supervision model can only punish medical institutions and cannot "supervise and punish people", which is an important reason. By establishing a qualification management system for medical insurance payment, the regulatory reach is extended to specific responsible persons, and points management is carried out for those who violate regulations, highlighting the precision of supervision and making violators pay the appropriate price, which can effectively curb the abuse of medical insurance funds Yan Qinghui said. Gu Rong introduced that relevant measures will achieve nationwide networking linkage. Once the medical insurance payment eligibility is suspended or terminated in a designated medical institution, corresponding measures will also be taken in other designated medical institutions. If a region is scored and processed, the information will be shared nationwide, achieving cross institutional and cross regional linkage. In addition, a 'one person, one file' system will be established. "In the long run, we will establish a 'one person, one file' medical insurance integrity file for the relevant personnel of the designated medical institutions. Everyone will get a unique ID code, which is the same as a personal ID card in the national medical insurance system, and is unique for life, not changing with the registered residence address and residential address." Gu Rong said that everyone will also have their own medical insurance integrity file, comprehensively recording their score and other compliance with medical insurance related laws and regulations, along with their entire career. The collaboration of the "three doctors" forms a joint regulatory force for medical insurance fund supervision, which cannot be separated from the collaboration of medical insurance, healthcare, and pharmaceuticals. Gu Rong stated that the medical insurance department will inform the health department and drug regulatory department of the situation related to scoring, suspension, and termination of personnel, and further strengthen the management of relevant personnel according to their responsibilities, jointly forming a regulatory force. Xing Ruoqi, Deputy Director of the Medical Administration Department of the National Health Commission, stated that the commission regards regulating the behavior of medical institutions and maintaining the safety of medical insurance funds as important contents of the "2024 Key Points for Correcting Unhealthy Practices in the Field of Pharmaceutical Purchase and Sale and Medical Services", and focuses on strengthening supervision and inspection. We will organize the verification of cases with high abnormal hospitalization expenses, establish a long-term mechanism for hierarchical monitoring, traceability, and continuous supervision, and standardize behaviors such as diagnosis, treatment, and fees. We will focus on using medical insurance funds in accordance with laws and regulations, organize inspections of large hospitals, and urge medical institutions to improve internal management. In addition, based on the previous cooperation with the National Medical Insurance Bureau to jointly develop the annual inspection work plan and typical problem list, we will continue to cooperate with the National Medical Insurance Bureau to organize the notification and warning education of typical cases of illegal and irregular use of medical insurance funds. Medicines are an important guarantee for medical and health services. Zhou Le, Deputy Director of the Drug Supervision Department of the National Medical Products Administration, stated that the National Medical Products Administration has improved its regulatory system and consolidated the foundation of drug supervision; Strengthen the supervision of the production process and carry out in-depth actions to consolidate and enhance drug safety; Strengthen the supervision of drug management processes, increase monitoring of online drug sales, and adhere to integrated online and offline supervision. The National Healthcare Security Administration actively strengthens cooperation with the National Health Commission, the National Medical Products Administration, and other departments, regards the establishment of a medical insurance payment qualification management system as an important part of improving the medical insurance fund supervision system, and fully promotes its implementation Yan Qinghui said. (New Society)
Edit:Chen Jie Responsible editor:Li Ling
Source:People's Daily
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