The "Regulations" will greatly improve the level of modernization and legal governance of medical insurance, and provide legal guarantee for promoting the safe and effective use of medical insurance funds. What terms are worthy of attention? How can Guangdong weave a strict cage for fund supervision and manage the "life-saving money" of ordinary people?
Guangzhou Daily Xinhua City reporter interviewed the relevant person in charge of Guangdong Provincial Health Insurance Bureau.
Strengthen supervision measures in all directions
For a long time, the medical insurance fund has many users, long chain, many risk points and difficult supervision. There is no unified and clear regulation on the use of funds, and the problem of fraudulent insurance continues to occur frequently. It is very important to maintain the security of medical insurance fund.
The full text of the Regulations, which has been formally implemented, consists of five chapters and 50 articles. It proposes to implement people's health-centered requirements, strengthen medical security services, clarify the responsibilities of medical insurance administrative departments, agencies, designated medical institutions, insured persons and other related subjects in the use of funds, standardize the use of funds, establish and improve supervision, supervision and law enforcement mechanisms, stipulate supervision forms, standardize supervision and inspection measures and procedures, comprehensively strengthen supervision measures, refine legal responsibilities and increase punishment.
What rights does the insured enjoy?
Medical insurance fund is the "medical money" and "life-saving money" of the people, and its use safety is related to the vital interests of the people. These Provisions shall apply to the use, supervision and management of basic medical insurance (including maternity insurance) funds, medical assistance funds and other medical insurance funds in China.
The Regulations clarify the rights of the insured.
Insured persons have the right to seek medical treatment and purchase medicines, and enjoy medical security benefits according to regulations;
Have the right to request medical security institutions to provide medical security consulting services, and supervise medical security administrative departments, medical security institutions and designated medical institutions;
Have the right to report and complain about violations of laws and regulations of medical insurance funds;
Have the right to state and defend, and have the right to apply for administrative reconsideration or bring an administrative lawsuit according to law.
Entrusted drug purchase requires identification by both parties.
The Regulations clarify the responsibilities of different subjects such as medical security administrative departments, medical security agencies, designated medical institutions and insured persons.
For example, for the insured, it is necessary to seek medical treatment and purchase medicine with the medical security certificate, and take the initiative to show it for inspection. Take good care of my medical insurance certificate to prevent others from using it. If it is necessary to entrust others to purchase drugs for special reasons, the identity certificates of the principal and the trustee shall be provided. Enjoy medical security benefits in accordance with the regulations, and may not enjoy them repeatedly.
The Regulations also provide for the establishment of a supervision mechanism combining government supervision, social supervision, industry self-discipline and personal trustworthiness, and make arrangements for the establishment of a supervision and cooperation mechanism for medical insurance, health, Chinese medicine, market supervision, finance, auditing, public security and other departments. The above departments are required to work together, establish mechanisms such as communication and coordination and case transfer, and do a good job in the supervision and management of the use of medical security funds.
Designated institutions or individuals cheat insurance, and fines can't escape.
The Regulations provide a standard for the supervision of the use of medical insurance funds in China from the aspects of supervision contents, institutions, methods and legal responsibilities. The rights and responsibilities of the supervisor are clear, and the supervision and management mechanism in the use of medical insurance funds is established.
For example, if a designated medical institution violates the internal management regulations, the administrative department of medical security shall order it to make corrections, and may interview the relevant person in charge. Those who refuse to make corrections shall be fined 1 10,000 yuan but not more than 50,000 yuan;
Violation of other laws and administrative regulations shall be dealt with by the relevant competent departments according to law;
For insurance fraud, the administrative department of medical security shall order it to be returned and impose a fine of more than 2 times and less than 5 times the amount of fraud; Ordering designated medical institutions to suspend the use of medical services involved in the medical insurance fund for more than 6 months 1 year, until the medical insurance agency terminates the service agreement; Those with professional qualifications shall be revoked by the relevant competent departments according to law.
For another example, in addition to the above provisions, the administrative department of medical security should also impose a fine of more than 2 times and less than 5 times the amount defrauded.
Guangdong investigated and dealt with illegal medical institutions in one year 16785.
Guangdong Provincial Medical Insurance Bureau adheres to the principle of long-term effectiveness and strictness, strengthens the supervision of medical insurance funds, promotes the coordinated supervision of departments, innovates the supervision methods of medical insurance funds, and carries out in-depth special treatment to combat fraud and insurance fraud, so as to keep the people's "life-saving money".
The Provincial Medical Insurance Bureau organized the province to carry out self-examination, self-correction, spot check and review, special treatment and cross-examination in the province, and took various measures to safeguard the safety of medical insurance funds.
In 2020, the province's medical insurance departments inspected 3883 1 designated medical institutions and handled 16785 violations (of which 1 1 was transferred to judicial organs), involving 65 1 10,000 yuan of medical insurance funds; 2. Institutions that handle medical insurance in violation of regulations; 869 offenders were dealt with. There are 33 provincial cross-check medical institutions, including 23 public medical institutions and non-public 10.
According to the relevant person in charge of the Guangdong Provincial Medical Insurance Bureau, the inspection found that the above-mentioned medical institutions were found to have fictitious services (false settlement, induced hospitalization), exchange fees (diagnosis and treatment items, medicines, consumables), irregular diagnosis and treatment, and unreasonable fees. * * The cases involved are about 6.5438+0.436 million, and the amount of violation is about 6.5438+0.2624 million yuan.