Recently, a number of hospitals have been found to have used medical insurance in violation of laws and regulations**.
According to the announcement of the 2022 annual medical insurance flight inspection of the National Medical Security Administration, all of the 48 designated medical institutions that were randomly inspected have the problems of duplicate charges, excessive standard charges, and decomposition project charges. The state has established a basic medical insurance system, through the payment and financing of the state, units and individuals, and the establishment of basic medical insurance for mutual assistance, with the aim of providing compensation for the cost of medical treatment for the people and reducing the economic burden of the people. Medical insurance is the people's "medical money" and "life-saving money", strictly abide by the "red line" of medical insurance, and weave a dense regulatory network is the primary task.
Article 20 of the Regulations on the Supervision and Administration of the Use of Medical Security** clearly stipulates that medical security agencies, designated medical institutions and other units, as well as their staff and insured persons, shall not fraudulently obtain medical security ** by forgery, alteration, concealment, alteration, destruction of medical documents and other relevant information, or fabrication of medical service items. Attaches great importance to the safety of medical insurance. The general secretary has made important instructions on maintaining the safety of medical insurance for many times, clearly requiring the strengthening of medical insurance supervision, and there are still people who want to extend the "life-saving money" to the people, and the problem of non-standard use is still frequent.
The insurance fraud methods of medical institutions are becoming more and more detailed and hidden, and the content of medical information is professional and complex, which has caused great difficulty in the supervision of medical insurance. It is urgent to guard the people's "medical money" and "life-saving money", and further strengthen the supervision of medical insurance.
First of all, further improve the social security legal system such as medical security, consolidate the legal foundation of medical insurance supervision, and make the supervision of medical insurance more standardized and effective. In order to further guard the people's "medical money" and "life-saving money", the General Office issued the "Implementation Opinions on Strengthening the Normalized Supervision of the Use of Medical Security" this year, making it clear that it will accelerate the construction of a normalized supervision system for the use of medical insurance with clear rights and responsibilities, strict and powerful, safe and standardized, and efficient under the rule of law. Qiao Ning, a lecturer at the Department of Health Law of the School of Medical Humanities of Capital Medical University, believes that at present, China's criminal law and social insurance law have provisions on the punishment of insurance fraud and some provisions on supervision, but there is no regulation of the whole process of illegal use of medical insurance. Improving the medical insurance safety supervision system on the track of rule of law is the basis for protecting the rights and interests of the people and strictly abiding by the "red line" of medical insurance. It is an urgent task to enrich and refine the laws and regulations of medical insurance supervision and establish a legal system of medical insurance supervision from multiple perspectives.
Secondly, promote the construction of a multi-faceted medical insurance supervision system, strengthen the accountability and punishment of violations of laws and regulations, and build a high wall of medical insurance supervision. On the one hand, we should improve and improve the supervision and inspection system, intelligent monitoring, reporting reward, credit management, comprehensive supervision, social supervision and other external regulatory systems of the industry, so as to jointly ensure the safety and reasonable use of medical insurance. Meng Yanchen, an associate professor at the School of Medical Humanities of Capital Medical University, said that the establishment of a scientific and effective regulatory mechanism requires the joint efforts of the government, society and hospitals to strengthen the supervision and management of the use of medical insurance in an all-round way, and promote the organic combination of supervision, social supervision, industry self-discipline and personal trustworthiness. The "Opinions" clearly pointed out that the communication and coordination between the medical insurance department and the public security, finance, health, traditional Chinese medicine, market supervision, drug supervision and other departments should be strengthened, information exchange and sharing should be promoted, and the mutual transfer of clues, standards and results between departments should be realized. On the other hand, it is necessary to strengthen the effective connection between administrative law enforcement and criminal justice before, during and after the event, and severely crack down on illegal and criminal acts in the field of medical insurance in accordance with the law. Promptly transfer leads on suspected violations of discipline, violations of public office, or crimes abusing public office to the discipline inspection and supervision organs, establish and complete mechanisms for joint investigation and handling of important leads and major cases, and for pursuing accountability, to strengthen the deterrent effect.
Finally, there are many medical insurance supervision points, long lines and wide coverage, and in order to weave a dense regulatory network, it is necessary to use information technology such as big data to empower medical insurance supervision. In May 2023, the National Health Insurance Administration announced the "Framework System for Intelligent Review and Monitoring of Medical Security** Knowledge Base and Rule Base (1.).Version 0), in which the knowledge base is the knowledge and basis required for intelligent audit monitoring, and the rule base is based on the "red line" drawn by the knowledge base for violations of laws and regulations. By clarifying the knowledge base and rule base, the medical insurance department can move the regulatory threshold forward through the intelligent supervision system, automatically intercept "clear violations", and prompt "suspicious" behaviors that violate fair use rules. In 2022, with the help of the establishment of a "false hospitalization" model and big data analysis, the National Health Insurance Administration completed the screening and analysis of nearly 3.8 billion massive data from more than 420,000 designated medical institutions across the country in one week, and found suspicious clues, effectively solving the problem of difficult and inefficient traditional manual verification. According to the National Health Insurance Administration, at present, more and more designated hospitals take the initiative to achieve self-inspection and self-correction with the help of intelligent monitoring, reduce the occurrence of violations, and minimize the responsibility or punishment after the fact. The intelligent audit and monitoring system has become the "first line of defense" for medical institutions to use medical insurance in a safe and standardized manner.
As the material basis and power source for the healthy operation of the medical insurance system, medical insurance is related to the well-being of the people and social stability. With the deepening of medical insurance reform, the application scenarios of the medical insurance system will become increasingly diversified and refined, and the use and supervision of medical insurance will face the challenges of more points, longer lines and wider coverage. Only by weaving a tightly woven regulatory network, strictly abiding by the "red line" of medical insurance, and ensuring that every penny is spent on the cutting edge, can the people have a greater sense of gain, happiness and security in a fair, transparent and efficient medical service system.
* |Red Net.
Edit |Yang Zixuan, Zhang Wenqing.
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