Many places have announced the supervision of medical insurance in 2023, and the role of anti-corruption "searchlight" of medical insurance supervision will continue to be strengthened in 2024.
Notification of medical insurance violations in many places
Some of them were handed over to the judiciary
Recently, many places have disclosed the progress of medical insurance supervision.
Previously, medical insurance flight inspections, key inspections and special rectifications were carried out in turn, and inspection teams were stationed in major hospitals. Among the disclosure issues, problems such as collusion of drugs, medical consumables, diagnosis and treatment items and service facilities, decomposition of hospitalization, inconsistency between the purchase, sale and inventory of drugs and medical consumables, excessive standard charges, and excessive inspections have been frequently raised. Some designated medical institutions were fined, their medical insurance service agreements were terminated or suspended, and some of them were handed over to the judicial authorities.
Recently,LiaoningThe National Health Insurance Bureau issued the "Liaoning Provincial Medical Security Bureau's 2023 Provincial Medical Insurance ** Supervision Flight Inspection Announcement", and the province organized a total of 16 provincial flight inspection teams last year to complete the annual flight inspection task covering 14 cities.
Among them, the provincial flight inspection team inspected 32 designated medical institutions on site. In terms of level, there are 20 companies, 11 companies in the second level, and 1 company that has not been graded; In terms of nature, there are 26 public companies and 6 private companies.
The main problems of medical insurance violations are as follows:
After the provincial flight inspection team transfers the problems found in the inspection to the inspected city, the medical insurance bureau of the inspected city organizes forces to review them one by one, and deal with the designated medical institutions with problems in accordance with laws and regulations. By the end of 2023, medical insurance **3484 has been recovered190,000 yuan, and imposed an administrative fine of 466 on 7 designated medical institutions990,000 yuan, 5 designated medical institutions will be punished with liquidated damages or deducted 126 deposits030,000 yuan, and some issues are still being further reviewed and processed.
In 2023, the medical insurance departments of various cities in Liaoning will carry out daily supervision, key inspections and special rectifications on a regular basis, actively investigate and deal with reports and complaints, severely crack down on fraud and insurance fraud with a zero-tolerance attitude, and resolutely adhere to the bottom line of medical insurance safety. A total of 37,163 designated medical institutions were inspected in the province, and the on-site inspection was fully covered, and the medical insurance was punished and recovered**65.8 billion yuan, 568 medical insurance service agreements were terminated or suspended, 17 were transferred to judicial organs, and 13 were transferred to discipline inspection and supervision organs.
On January 19th,XinjiangThe Health Insurance Bureau issued the "Announcement on the 2023 Annual Medical Insurance ** Unannounced Inspection of the Medical Security Bureau of the Autonomous Region", and in 2023, 14 unannounced inspection teams will be organized to go to 36 counties (cities and districts) in 14 prefectures (prefectures and cities) to carry out unannounced inspections of 50 designated medical institutions (10 ** medical institutions, 30 secondary medical institutions, and 10 first-level and below medical institutions).
During the inspection, the flight inspection team found that the medical institutions at the inspected point had medical insurance management problems and illegal problems such as repeated charges, excessive standard charges, decomposition project charges, excessive diagnosis and treatment in violation of diagnosis and treatment norms, excessive inspection, excessive medical insurance payment and limited drug use, collusion of diagnosis and treatment items, and inclusion of medical expenses that are not within the scope of medical insurance payment into medical insurance ** settlement, and was suspected of using medical insurance ** 40 million yuan in violation of laws and regulations.
Up to now, 29.92 million yuan of medical insurance has been recovered, 7 designated medical institutions have been fined 2.43 million yuan, and 12 designated medical institutions have been fined 400,000 yuan, and some problems are still being further reviewed and handled. At the same time, according to the severity of the problem found in the flight inspection, the local medical insurance departments will make corresponding interviews, order rectification, circulate criticism, suspend and terminate the medical insurance service agreement, and transfer to the judicial organs and discipline inspection and supervision organs for punishment in accordance with laws and regulations.
YunnanThe Medical Insurance Bureau disclosed that from January to November 2023, medical insurance departments at all levels in Yunnan Province investigated and dealt with a total of 14,449 designated medical institutions that violated laws and regulations, investigated and dealt with 2,560 cases of violations of laws and regulations by insured persons, transferred 82 people to judicial organs, imposed administrative penalties on 26 companies (people), and recovered 5 losses from medical insurance5.6 billion yuan, and 689 typical cases were disclosed.
According to Yunnan** report, since 2023, the Yunnan Provincial Medical Insurance Department has jointly arranged and deployed special rectification work to combat fraud and insurance fraud, and severely cracked down on key areas such as orthopedics, blood purification, cardiovascular medicine, inspection and testing, and physiotherapy, as well as key fraud and insurance fraud such as collusion of drugs, medical consumables, false medical treatment, and reselling of medical insurance drugs, and the medical insurance department investigated and dealt with 8,079 designated medical institutions that used medical insurance in violation of laws and regulations. Investigated and punished 56 people who resold medical insurance drugs, and recovered the loss of medical insurance **2$4.8 billion; The Provincial Department of Finance and the Provincial Health Commission jointly carried out provincial unannounced inspections of designated medical institutions and medical insurance agencies in 16 prefectures (cities).
The intelligent system pulls up the regulatory net
Give play to the role of a "searchlight" in the fight against corruption
At present, the situation of medical insurance supervision is different from the past, with the strengthening of supervision and the intervention of new regulatory means, the role of the "searchlight" of pharmaceutical anti-corruption has been further stimulated.
The National Medical Security Work Conference held on January 9 made it clear thatIn 2024, it is necessary to strengthen the high-pressure situation of supervision. Achieve comprehensive coverage of on-site supervision and precise crackdown on off-site supervision, and give full play to the role of a searchlight to govern corruption in the pharmaceutical field. Cooperate with multiple departments to carry out special governance in key areas, and effectively give full play to the role of "promoting reform through investigation".
In May last year, the General Office of the People's Republic of China issued the "Implementation Opinions of the General Office on Strengthening the Normalized Supervision of the Use of Medical Security", which clarified that "increase the supervision and law enforcement of medical insurance, effectively implement the regulatory responsibilities of all parties, strengthen the construction of regulatory capacity, and comprehensively use a variety of regulatory methods", "Crack down on fraud and fraud, hedging and misappropriation of medical insurance with a zero-tolerance attitude".
Cross-departmental comprehensive supervision, execution linkage, normalization of intelligent monitoring, and improvement of the reporting and complaint mechanism all appear in this document.
On February 4, the National Health Insurance Administration held an annual work summary meeting. Zhang Ke, Secretary of the Party Leadership Group and Director of the National Health Insurance Bureau, made an annual work summary. Relevant comrades of the Organization Department, the Discipline Inspection Commission and the State Supervision Commission in the Discipline Inspection and Supervision Group of the National Health Commission also attended the meeting. The meeting proposed to implement the major decisions and deployments on medical security work to the letter.
Zhang Ke, the new director of the National Health Insurance Administration this year, has long-term work experience in the audit department, and has served as a member of the party group and chief auditor of the Audit Administration, a member of the party group and deputy auditor general of the Audit Administration.
It has been observed that audit work continues to play a role in the medical field.
In December last year, the Hangzhou Municipal Audit Bureau issued the "Announcement on the Special Audit Survey Results of Hangzhou's Medical, Medical Insurance and Pharmaceutical Linkage Reform", and the main problems found in the audit include the lack of refinement of the rules for adjusting the total budget growth rate of hospitalization expenses in the reform of the medical security system, the failure to settle the payment subsidy for basic medical insurance for employees in a timely manner, the procurement of high-value medical consumables under the storage of some public medical institutions, and the lack of dynamic management of designated medical institutions.
In addition, in the audit of the economic responsibility of the city's medical insurance bureau, the Nanjing Municipal Audit Bureau focused on the implementation of medical insurance policies, capital security and business operation around the management and use of medical insurance, revealed potential risks, and improved the quality and efficiency of supervision. Review the trend of income, expenditure and balance, review the deposit, and pay attention to the account management. Pay attention to the compliance of medical insurance expenditure, review whether the business of the handling agency has exceeded the scope, proportion, and standard payment of medical insurance, and jointly research, analyze, and put forward countermeasures and suggestions for the universality, tendencies and emerging problems in the management and use of medical insurance.
As a new force in supervision, the intelligent supervision platform is also playing a greater role, among which the abnormal use of drugs and consumables has been discovered.
Last year, Yunnan Province organized and implemented the 2022 provincial flight inspection to "look back" at the rectification of problems found in the province; Jointly with the public security, health and civil affairs departments to establish a multi-departmental data sharing and abnormal data screening mechanism, through data comparison, screened out 38,336 pieces of reimbursement information after the death of the insured in the province, and verified and recovered 464 medical insurance130,000 yuan.
It is understood that a total of 17 co-ordination districts in 16 prefectures (cities) in Yunnan Province have all deployed intelligent audit and monitoring systems, and as of the end of November 2023, the province has reminded a total of 442 violations in advance760,000 times. Carry out horizontal and longitudinal analysis and comparison of the data on the increase in cost and cost composition after centralized collection of cardiac stents, and interview hospitals with abnormal increase in balloon catheter and abnormal increase in average hospitalization costs, so as to promote hospitals to reduce medical costs.