In order to further strengthen the management of designated medical institutions for medical insurance, improve the quality of medical services and ensure the safety of medical insurance funds, according to the Opinions on Strengthening the Management of Current Medical Insurance Agreements,
Notice on Ensuring the Safety of Funds (No.218 of the Medical Insurance Office), issued by the Office of the State Medical Insurance Bureau and the General Office of the Ministry of Finance.
Notice of the Interim Measures for Reporting Cheating Medical Insurance Fund Awards (Medical Insurance Office [
2018 No.22) and other regulations, the relevant matters concerning further improving the management of medical insurance designated medical institutions in our city are hereby notified as follows:
First, adjust the application conditions.
In accordance with the principles of openness, fairness, convenience and efficiency, the application conditions of designated medical institutions for medical insurance shall be adjusted. Medical institutions applying for the management of designated medical insurance agreements shall meet the following basic conditions:
(1) Designated medical institutions
1. Comply with relevant laws, regulations and policies on medical services, medical prices and social insurance. And has not been subject to administrative punishment by market supervision, health care, human society and other departments within 6 months before the date of application.
2. Hold the Practice License of Medical Institution or the Registration Certificate of Chinese Medicine Clinic, and the corresponding business license (institution registration certificate or private non-enterprise unit registration certificate).
3, places, medical personnel, equipment and other settings must comply with the relevant provisions of the health department, the business address should be consistent with the business license (enterprise legal person registration certificate or private non-enterprise unit registration certificate).
The stated information is consistent. If it is unnecessary and fails to apply for the above license according to law, the business address shall be consistent with the information specified in the Practice License of Medical Institution or the Record Certificate of Chinese Medicine Clinic.
4. Commitment to implement the medical insurance policies and regulations after the designated medical insurance, establish and improve the medical service management system including the medical insurance physician management assessment system, and equip relevant personnel, equipment and information systems to meet the needs of basic medical insurance management services.
5. Formulate and implement a complete and standardized "purchase, sale and storage" system and financial management system for drugs and medical materials to ensure the preparation and use of drugs in the medical insurance catalogue and ensure that the insured enjoy compliance treatment. Establish and operate an information management system that can provide "purchase, sale and storage" in real time, and save relevant materials and records for future reference.
6. Promise to install audio and video monitoring system in the credit card settlement system and the dispensing area within the visual range after the medical insurance is designated, and open the corresponding authority to the medical insurance administrative department and the medical insurance agency for real-time viewing or later access.
7. Sign labor contracts with employees according to law, and participate in and pay social insurance according to regulations.
Branches of medical institutions and cooperative (cooperative) hospitals should apply for the management of designated medical insurance agreements respectively.
(2) Designated retail pharmacies
1. Abide by relevant laws, regulations and policies such as drug management, price management and social insurance. , and establish relevant management systems, and have not been subject to administrative penalties such as market supervision and human resources departments within 6 months before application.
2. Hold a drug business license, corresponding business license and good manufacturing practice (GSP) certification.
3. The establishment of the premises and equipment shall comply with the relevant regulations of the market supervision department, and the business address shall be consistent with the information specified in the business license.
4. There shall be no less than 2 pharmacists (Chinese pharmacists), including at least 1 licensed pharmacist. Licensed pharmacists and pharmacists shall not be named (check their registration certificates, social insurance payment vouchers, labor contracts and other related materials) to ensure that at least 1 licensed pharmacist is on duty during business hours. Pharmacies dealing in Chinese herbal medicines should be equipped with 1 Chinese medicine professionals with technical titles of Chinese pharmacists or above.
5. Formulate and implement a complete and standardized "purchase, sale and storage" system and financial management system for drugs approved for sale. Establish and operate an information management system that can provide "purchase, sale and storage" in real time, and save relevant materials and records for future reference.
6. Commit to install audio and video monitoring system within the visual range of the credit card settlement system and the dispensing area after the medical insurance is designated (if other commodities such as health care products are operated with the approval of relevant departments, the exhibition area, settlement counter and settlement system are set separately, and the audio and video system can be covered), and open the corresponding authority to the medical insurance administrative department and the medical insurance agency for real-time viewing or later reference.
7. Sign labor contracts with employees according to law, and participate in and pay social insurance according to regulations.
Stores of pharmaceutical retail chain enterprises should apply to designated medical insurance institutions separately.
Second, establish a negative list system for access.
Medical insurance agencies shall not accept designated applications for medical insurance of medical institutions under any of the following circumstances within a certain period of time:
(1) Providing false application materials
For medical institutions and their legal representatives and major investors who provide false information in the application process, since the date of verification, the medical insurance agency will record their dishonesty and push it to the public credit platform at the same level, and will no longer accept the application of this medical institution within 3 years.
(2) The medical insurance service agreement has been cancelled.
The designated medical institution terminates the medical insurance service agreement, including the name, address of business premises and legal representative or person in charge after the termination of the service agreement (subject to the registration records and relevant documents of the issuing authority). Within 3 years from the date of termination of the medical insurance service agreement, the medical insurance agency will no longer accept its application.
(three) included in the list of dishonesty
Medical institutions and their legal representatives and responsible persons have serious acts of dishonesty (subject to the query results of the public credit platform at the same level), and medical insurance agencies will not accept their designated medical insurance applications.
Third, standardize work processes and rules.
The medical insurance agency shall publish the application conditions, materials and forms, institutions, time, place, methods and workflow of designated medical institutions for medical insurance through the government website. The medical insurance agency shall establish an internal work management system and formulate corresponding forms to ensure that the whole process is fair, open and just. The workflow and rules are as follows:
(1) Voluntary application, registration and acceptance
1. Medical institutions that meet the application conditions for fixed-point agreement management and voluntarily undertake basic medical insurance services shall submit a written application to the local medical insurance agency and submit the required materials at the same time. Medical institutions within the urban area of Yangzhou submit a written application to the municipal medical insurance agency, and medical institutions within the county (city) submit a written application to the local medical insurance agency.
2 medical insurance agencies shall timely register the materials declared by medical institutions. If the application materials are complete and conform to the prescribed form, the medical insurance agency shall issue an acceptance certificate within 5 working days from the date of registration; If the application materials are incomplete or do not conform to the prescribed form, the applicant shall be informed in writing on the spot or within five working days of all the contents that need to be supplemented. If the applicant fails to make corrections within five working days after receiving the written notice, it shall be deemed to have withdrawn the application.
3. Under any of the following circumstances, the medical insurance agency will not accept the designated medical insurance application of the medical institution, and inform the reasons for rejection according to the regulations: it does not meet the basic conditions and standards for the management of designated agreements; Failing to declare relevant materials according to the specified time and content, and the application materials are incomplete or do not conform to the specified form; Belonging to the circumstances listed in the negative list of access.
(2) Material review and on-site review
Medical insurance agencies shall conduct preliminary examination on the application materials submitted by medical institutions and put forward preliminary examination opinions. On-site review of units that have passed the preliminary examination.
(3) Comprehensive evaluation and collective consideration
Medical insurance agencies shall set up a medical insurance designated medical institutions review group (hereinafter referred to as the review group), and review the medical institutions applying according to the application conditions of medical insurance designated, combined with the preliminary examination of materials and on-site review. The members of the evaluation team are composed of relevant experts, industry associations, insured units and insured persons. The assessment team of Yangzhou City is dispatched by the municipal and district medical insurance agencies.
The list of new designated medical institutions approved by the review group shall be publicized by the medical insurance agency.
(four) social publicity, negotiation and signing.
1. The list of new designated medical institutions will be publicized for one week through the government websites of local medical insurance administrative departments and medical insurance agencies. During the publicity period, medical institutions that have been strongly reflected by the masses and verified by the review team as not meeting the application conditions for designated medical insurance shall be removed from the list to be added; There is no objection or objection to the medical institutions during the publicity period, but after verification, the medical insurance agency will publish the evaluation results of the designated medical insurance agreement management. The evaluation results are only used for the agreement signed by the medical insurance agency at that time.
2, medical insurance agencies comprehensively consider the service ability and characteristics, medical insurance fund support ability and information system construction, as well as the insured's intention to seek medical treatment and other factors, equal communication, consultation and negotiation with medical institutions.
The two sides signed a service agreement after consultation to determine the management relationship of medical insurance fixed-point agreement. When signing a service agreement, a medical institution shall issue a written credit commitment at the same time, ensure law-abiding operation, be honest and trustworthy, and abide by various laws, regulations and policies related to the management of designated medical institutions in the future agreement period.
Failure to sign the agreement within the agreed date due to medical institutions shall be deemed as automatic waiver. If we can't reach an agreement, we won't sign the agreement. Medical institutions that have not signed a service agreement need to reapply and re-evaluate if they apply for medical insurance.
3, medical insurance agencies from the date of acceptance to complete the negotiation time limit, in principle, no more than 60 working days. Special circumstances need to extend the time limit, must be approved by the administrative department of medical insurance at the same level.
4, outpatient special diseases and special drugs in designated medical institutions for medical treatment.
Four, strengthen the supervision of designated medical institutions.
(A) to strengthen the management of daily agreements
According to the principle of territorial management, the regional agency is responsible for the daily agreement management of designated medical institutions within its jurisdiction. County (city) medical insurance agencies need to summarize the medical insurance service information of local fixed-point agreement management medical institutions every year and report it to the medical insurance administrative department at the same level for the record, and the municipal medical insurance agency and the county (city) medical insurance administrative department report it to the municipal medical insurance administrative department for the record.
1. Improve the service agreement text. The municipal medical insurance agency is responsible for drafting the unified service agreement format text of the whole city, and making timely adjustments according to the medical insurance policies and management requirements. While agreeing on the responsibilities and obligations of designated medical institutions and standardizing the overall quality and requirements of medical services, it is also necessary to reflect the responsibilities and obligations of employees. Take corresponding measures for employees who break the contract according to the situation until the real-time settlement service of medical insurance is suspended or terminated, and refuse to pay for the medical services provided by them. Each (county, city) medical insurance agency may supplement the relevant service agreement according to the municipal text content and local conditions.
2. The validity of the agreement can be divided into short-term and long-term. The validity period of the first signed agreement is generally not more than 2 years. After the expiration of the agreement, the designated medical institutions have no illegal activities during the agreement period, and the validity period of the renewal agreement is 3 -5 years (the specific period is decided by the local agencies themselves, but the validity period of the renewal agreement in the same overall area should be consistent); If the designated medical institutions violate laws and regulations during the agreement period, but the agreement is not dissolved, the validity period of the renewal agreement is 1 year.
3, the establishment of designated medical institutions medical insurance service information change audit filing system. When the medical insurance service information of designated medical institutions changes, the original and photocopy of the medical institution's practice license (Chinese medicine clinic registration certificate), drug business license and corresponding business license (legal person registration certificate or private non-enterprise unit registration certificate) shall be provided. If there is a license cancellation, re-registration or re-handling, it shall be handled according to the procedures of the new medical insurance designated institutions.
(1) If a designated medical institution needs to change its name, person in charge, licensed pharmacist, etc. , shall, within 15 days after the change, hold a written application for change, the original and photocopy of the changed registration certificate and other materials to the medical insurance agency to go through the examination procedures for the change of medical insurance service information. If the designated medical institution fails to handle or fails to handle the above-mentioned medical insurance service information change review procedures within the time limit, it shall be handled according to the service agreement.
(2) If a designated medical institution needs to change its business address or legal representative (operator), it shall inform the regional medical insurance agency in writing 15 days in advance, and the original agreement shall be terminated within 15 days after the license is changed, and it shall go to the medical insurance agency to go through the examination procedures for the change of medical insurance service information with the written application for change, the original and copy of the changed registration license and other materials. The medical insurance agency shall handle it in accordance with the procedures of the new designated medical insurance agency. If the designated medical institution fails to handle or review the above-mentioned medical insurance service information changes within the time limit, the original agreement will be terminated automatically.
(3) The medical insurance agency shall timely report the information review of medical insurance service changes of designated medical institutions to the medical insurance administrative department at the same level for the record.
4, the implementation of designated medical institutions identification system. Designated medical institutions shall hang the management signs of medical institutions with fixed-point agreements on basic medical insurance in a prominent position in their business premises, so as to facilitate public identification. The style and specifications of the sign shall be uniformly stipulated by the municipal medical insurance agency.
5. Establish and improve the intelligent audit system of medical expenses. Medical insurance agencies should standardize the data indicators of intelligent audit, expand the application of clinical rules, improve the breadth, accuracy and precision of intelligent audit, give full play to the efficiency of intelligent audit system, provide audit prompt information to designated medical institutions in time, realize pre-prompt, in-process monitoring and early warning and post-event responsibility tracing, and standardize medical service behavior.
6. Establish an evaluation system. Medical insurance agencies should establish and improve the assessment and dynamic management mechanism of fixed-point agreement management medical institutions, and clarify the violations and handling rules in medical insurance service agreements. It is necessary to carry out daily inspection and medical record review, unblock the channels for reporting complaints, and deal with the problems found in strict accordance with the agreement and assessment methods.
(two) the implementation of designated medical institutions exit mechanism.
The designated medical institution that commits one of the following acts shall terminate the service agreement: 1. Defrauding the medical insurance fund; 2. During the validity period of the agreement, the agreement has been suspended for three times, or it has not been rectified within the time limit or the rectification is not in place; 3. The Practice License of Medical Institution or the Registration Certificate of Chinese Medicine Clinic or the Business License is revoked (the registration certificate of public institution or the registration certificate of private non-enterprise unit); Refusing, obstructing or not cooperating with the administrative department of medical insurance or the medical insurance agency to carry out necessary supervision and inspection; 5.
By providing false information or other improper means to become a designated medical institution, which is verified to be true; 6. Other illegal or breach acts have serious consequences or significant impacts.
The service agreement shall be terminated if the designated retail pharmacy commits any of the following acts: 1. Defrauding medical insurance funds; 2. During the validity period of the agreement, the agreement has been suspended for three times, or it has not been rectified within the time limit or the rectification is not in place; 3. The Drug Business License or Business License has been revoked; Refusing, obstructing or not cooperating with the administrative department of medical insurance or the medical insurance agency to carry out necessary supervision and inspection; 5.
Taking improper means such as providing false information to become a designated retail pharmacy is verified to be true; 6. Other illegal or breach acts have serious consequences or significant impacts.
When drafting the text of the service agreement, the medical insurance agency shall agree to terminate the service agreement, including but not limited to the above terms.
(3) Strengthening the supervision and inspection of administrative law enforcement.
Local medical insurance administrative departments should adopt regular and irregular supervision methods, supervise and inspect the implementation of medical insurance policies, the signing and performance of agreements between medical insurance agencies and designated medical institutions, order the found violations of medical insurance laws and regulations to make rectification, and impose administrative penalties according to law; Involving the responsibilities of other administrative departments, handed over to the relevant departments for handling; Anyone suspected of committing a crime shall be transferred to the public security organ.
It is necessary to broaden the channels of supervision, innovate the methods of supervision, and explore ways to mobilize all sectors of society to participate in medical security supervision by investigating the satisfaction of insured persons, introducing third-party evaluation, and hiring social supervisors.
(D) Effective connection between administrative supervision and agreement management
Agencies in the implementation of daily agreement management, found that designated medical institutions have breach of contract, illegal behavior, according to the agreement for processing (processing results reported to the administrative department of medical insurance at the same level for the record) at the same time, illegal clues should be promptly handed over to the administrative department of medical insurance; Medical insurance administrative departments in the implementation of administrative law enforcement supervision and inspection, found that designated medical institutions have breach of contract, illegal behavior, in the implementation of administrative punishment according to law (punishment decision copied to the agency) at the same time, should inform the agency of the breach of contract. When necessary, a joint inspection unit shall be formed for inspection. Through the effective connection between administrative supervision and agreement management, we will form a joint force of medical insurance supervision to ensure that medical insurance supervision does not leave gaps or dead ends.
(5) Strengthen information exchange among departments.
Local medical insurance administrative departments and medical insurance agencies should take the initiative to strengthen communication with medical and health, drug supervision, market supervision, social security and other departments, establish an information sharing mechanism, timely notify each other of major events such as medical accidents, counterfeit and inferior drugs, and fraudulent insurance in designated medical institutions, and implement a mutual recognition linkage mechanism for the results of illegal treatment in designated medical institutions in the city.
(6) Strictly guard against the risks of clean government.
All localities should strengthen and improve the construction of internal control system of basic medical insurance, strictly implement internal control system and mechanism, and medical insurance administrative departments, medical insurance agencies and their staff should earnestly abide by the relevant provisions of honesty and self-discipline, take the initiative to accept the supervision of discipline inspection departments and social supervision, and put an end to corruption.
Verb (abbreviation for verb) Other matters
This notice shall come into force as of 20 19 10 1. If the relevant provisions promulgated by this Municipality are inconsistent with this notice, this notice shall prevail.
Before the implementation of this notice, the original agreement confirmed by the medical insurance agency in the overall planning area and within the validity period can continue to be performed, but if there are new provisions in laws, regulations, policies and this notice, the new provisions shall prevail. If the original agreement is inconsistent with the new regulations, the original agreement shall be amended and supplemented according to the new regulations after consultation between both parties, and its effect is the same as that of the original agreement. Within 30 days before the expiration of the original agreement, if a designated medical institution applies for renewal, the medical insurance agency shall negotiate with it on the contents of the agreement according to this notice, and the agreement can be directly renewed after consensus is reached.
Yangzhou medical security bureau
20 19
August 2, 20081day