In order to strictly implement the Interim Measures for the Administration of Medication in Basic Medical Insurance, the National Catalogue of Medicines for Basic Medical Insurance, Work Injury Insurance and Maternity Insurance, the scope and payment standard of basic medical insurance diagnosis and treatment projects and medical service facilities in Jiangsu Province, and the Catalogue of Special Medical Materials for Medical Insurance in Jiangsu Province, the implementation of the "On Strengthening"
The Notice on the Management of the Use of Drugs with Restricted Payment (Su Medical Insurance Letter [2021] No.200) requires that the management of drugs with restricted payment scope, diagnosis and treatment items and special medical materials should be further strengthened, the system cage should be tightened, the rational use of medical insurance funds should be ensured, the clinical rational medical care should be promoted, and the legitimate rights and interests of insured persons should be safeguarded. The relevant matters are hereby notified as follows:
First of all, improve the understanding of medical insurance quota payment.
Strengthening the supervision of the limited payment scope of medical insurance such as drugs, diagnosis and treatment items and special medical materials is an important measure to ensure the rational and effective use of medical insurance funds and maintain the safety of medical insurance funds. Local medical security departments and designated medical institutions should unify their thinking, raise awareness, earnestly enhance their sense of responsibility and mission, take measures to plug loopholes, strictly implement the medical insurance payment policy for drugs, diagnosis and treatment items and special medical materials, ensure the safety of medical insurance funds, and safeguard the medical security rights and interests of the majority of insured persons.
Second, correctly understand the limited payment scope of medical insurance.
The limited payment scope of medical insurance is the standard of whether the medical insurance fund pays. Insured patients can only be paid by the basic medical insurance fund if they meet the limited payment conditions of drugs, diagnosis and treatment projects and special medical materials. All localities should accurately understand the conditions of diseases, people, courses of treatment, days and so on stipulated in the medical insurance quota payment, and shall not adjust and expand or narrow the scope of medical insurance quota payment by themselves. Clinically, it must be used according to the needs of the disease, but it is not limited by the payment scope limited by medical insurance. However, the informed consent form should be fulfilled seriously, and the expenses should be borne by the patient himself and signed by the insured or his family.
Three, strictly implement the medical insurance payment policy.
Local medical insurance departments and designated medical institutions should strictly implement the limited payment policy for drugs, diagnosis and treatment projects and special medical materials. For drugs that are managed by dual channels and paid by single line among drugs negotiated by the state, it is necessary to strictly review the relevant disease diagnosis reports required for drug use, so as to prevent fraudulent medical security benefits by providing "false reports". For drugs limited to second-line use, it is necessary to carefully check the process of disease treatment and medication, strengthen the preparation and use of first-line drugs, and put an end to the direct use of second-line drugs for treatment. For drugs, diagnosis and treatment items and special medical materials with limited use days and dosage, it is necessary to strictly calculate the use days and dosage to prevent clinical use beyond time and dosage. For drugs, diagnosis and treatment items and special medical materials used by medical institutions and specialties at a limited level, it is necessary to check the qualifications of medical institutions and corresponding departments to prevent the use of professional qualifications beyond the hospital level and professional departments. For other drugs whose medical insurance limits the scope of payment, it is necessary to strengthen the audit to reduce and eliminate the occurrence of illegal payment.
Four, increase the training of medical insurance limit payment policy.
Local medical insurance departments should strengthen the guidance and training of designated medical institutions. All designated medical institutions should improve the organizational structure, improve the internal management system, carefully sort out the drugs, diagnosis and treatment items and special medical materials used by their own units, strengthen the publicity and interpretation of the medical insurance payment restriction policy, do a solid job in training medical personnel, improve their understanding and understanding of the medical insurance payment restriction policy, and compact the responsibility of medical personnel to strictly implement the medical insurance payment restriction policy; In daily work, it is necessary to strengthen the publicity of insured patients and do a good job of explanation.
Five, give play to the role of information system in the management of medical insurance limit payment.
All agencies shall, as far as possible, directly control drugs, diagnosis and treatment items and special medical materials that can limit the scope of payment through the medical insurance information system; It is necessary to strengthen the construction of medical insurance intelligent monitoring system, transform relevant medical insurance quota payment policies and regulations into intelligent monitoring rules and constantly improve them, so as to achieve the effect of intelligent monitoring in advance and reminding in the event. All designated medical institutions should strengthen the information management of drugs, diagnosis and treatment items and special medical materials within the scope of medical insurance payment limitation, implant monitoring rules for the use of medical insurance payment limitation in the information management system, give full play to the early warning function of the information system, and promptly remind and prompt medical personnel when using and settling medical insurance payment limitation drugs to prevent accounting settlement beyond the scope of medical insurance payment limitation.
Six, strengthen the supervision and management of medical insurance quota payment.
Local medical insurance departments should comprehensively use agreements, administrative and judicial means to strictly investigate violations of policies and regulations, illegal use of restricted payment drugs, diagnosis and treatment projects, special medical materials, etc., and safeguard the safety of medical insurance funds. To take a variety of ways to supervise and inspect the designated medical institutions, and not to pay the illegal medical insurance fees found, and to incorporate the inspection results into the assessment of the implementation of the year-end agreement; In violation of the provisions of the designated medical institutions or relevant departments, and in violation of the provisions of Article 38 of the Regulations on the Supervision and Administration of the Use of Medical Security Funds, it is necessary to deal with it in a timely manner; Designated medical institutions or insured persons, for the purpose of defrauding medical insurance funds, cheat medical insurance benefits by forging or altering false medical certification materials, resulting in the loss of medical insurance funds, shall be dealt with in accordance with Articles 40 and 41 of the Regulations on the Supervision and Administration of the Use of Medical Insurance Funds, and the clues shall be handed over to the public security and discipline inspection and supervision departments for joint punishment. The medical insurance doctors involved should be interviewed, graded, suspended and even disqualified in strict accordance with the Measures for the Administration of Medical Insurance Doctors. If the medical security department fails to fulfill the relevant obligations stipulated by laws and regulations, resulting in the loss of the medical insurance fund, it shall be handled in accordance with the relevant laws and regulations.
Seven. others
All localities should strictly implement the drugs, diagnosis and treatment items and special medical materials limited in the medical insurance annex. If the higher authorities adjust the limited payment scope of relevant medical insurance, the new regulations shall prevail.
Attachment:
1. drugs included in the national basic medical insurance, industrial injury insurance, maternity insurance drug list and medical insurance limited payment scope of negotiated drugs.
2. Take the National Drug List of Basic Medical Insurance, Work Injury Insurance and Maternity Insurance as an example.
3. The scope and payment standard of basic medical insurance diagnosis and treatment items and medical service facilities in Jiangsu Province (202 10727) has a medical insurance quota payment model.
Peripheral diagnosis and treatment project
4. The Catalogue of Special Medical Materials for Medical Insurance in Jiangsu Province (202 10727) contains materials with limited medical insurance coverage.