The first is to build a medical insurance law enforcement supervision system. In the past, the supervision of funds was generally handled by the agency, which had many disadvantages such as the separation of management and operation. In order to cooperate with the reform of medical insurance administrative management system, that is, the administrative department of medical security supervises the inspection and audit of designated medical institutions by agencies, and the agencies deal with the breach of contract of designated medical institutions. If administrative punishment is needed, it shall be handled by the administrative department of medical security at the same level; The administrative department of medical security has the right to order the agency to suspend or terminate the service qualification of medical (pharmaceutical) teachers, and order the agency to suspend or terminate the medical insurance service agreement. Defining the rights and responsibilities of administrative departments and agencies is helpful to build a medical insurance law enforcement supervision system and improve the administrative supervision ability of medical security departments.

Second, implement diversified fund supervision methods. It is proposed to promote the application of information technology in the field of fund supervision and give play to the role of social forces in the supervision of medical insurance funds. At present, China's annual medical insurance fund revenue and expenditure exceeds 2 trillion yuan, and the designated medical institutions are close to 500,000. With a wide range, a large number and many points, the difficulty of supervision can be imagined. It is obviously not enough to rely only on the personnel of local medical security administrative departments and supervision and law enforcement agencies. With the help of information technology, it is helpful to improve the efficiency of medical insurance supervision to realize pre-supervision and post-supervision Mobilizing third-party organizations, social supervisors and individuals to participate in the supervision of medical insurance funds is conducive to social propaganda and creates a social environment in which everyone consciously safeguards the safety of funds.

Third, establish a multi-sectoral joint supervision mechanism. There are usually two kinds of penalties for insurance fraud in current laws and regulations: one is economic punishment, and the other is the disqualification of designated medical institutions in hospitals. Because the illegal cost is relatively low, it is impossible to form an effective supervision mechanism. Some local governments have explored some medical insurance supervision methods, but they are only a small deterrent. Upload the relevant information of the subject listed in the list of joint disciplinary targets for dishonesty to the national credit information sharing platform and credit information sharing platforms at all levels to implement joint credit punishment; In conjunction with the administrative department of health or the department responsible for drug supervision and administration, comprehensive supervision shall be implemented, and designated medical institutions and individuals who violate relevant regulations shall be ordered to suspend business for rectification, revoke their practice (business) licenses and revoke their qualifications as medical (pharmaceutical) teachers. By establishing a multi-sectoral joint supervision mechanism, we will strengthen cooperation among law enforcement subjects and effectively enhance the deterrence of law enforcement.

Fourth, establish a two-way restraint mechanism for relevant stakeholders. The main targets of medical insurance fund supervision are designated medical institutions, agreement management doctors, pharmacists and insured persons. The difficulty of supervision is to prevent the three from forming "collusion between doctors and patients". If the medical service behavior is completely false, the designated medical institution that fraudulently defrauds the medical insurance fund shall terminate the medical insurance designated service agreement or impose a fine; Because of the organization and instigation of others to defraud the medical insurance fund expenditure, resulting in adverse social impact, cancel the qualification of medical (pharmacy) teachers; Renting (borrowing) my valid medical security certificate to others or designated medical institutions to defraud the insured and medical assistance objects of the medical security fund, depending on the seriousness of the case, shall be fined. Trying to achieve the purpose of restraining the behavior of three parties by restraining the behavior of either party. Law of People's Republic of China (PRC) on Basic Medical Care and Health Promotion Article 41 The State shall take various measures to encourage and guide social forces to set up medical and health institutions according to law, and support and standardize the cooperation between medical and health institutions run by social forces and medical and health institutions run by the government in various medical services, discipline construction and personnel training. Medical and health institutions run by social forces enjoy the same rights as medical and health institutions run by the government in basic medical insurance, key specialty construction, scientific research and teaching, rating, access to specific medical technologies, and evaluation of professional titles of medical and health personnel. Social forces can choose to set up non-profit or for-profit medical and health institutions. Non-profit medical and health institutions run by social forces enjoy the same policies as medical and health institutions run by the government in taxation, financial subsidies, land use, water use, electricity use, gas use and heat use, and accept supervision and management according to law.

Legal basis:

Notice of the Office of the State Medical Insurance Bureau on Carrying out the Work of "Two Pilots and One Demonstration" in Medical Insurance Fund Supervision (No.[20 19] 17);

All provinces, autonomous regions, municipalities directly under the Central Government and Xinjiang Production and Construction Corps Medical Security Bureau:

In order to innovate the supervision mode, improve the supervision efficiency, and accelerate the construction of a long-term fund supervision mechanism, according to the requirements of the Notice of the National Medical Insurance Bureau on Doing a Good Job in the Supervision of Medical Insurance Funds in 20 19 (No.4 of Medical Insurance Fa [2065438]/KLOC-0), recommended by the medical insurance departments of various provinces (autonomous regions and municipalities), the national medical insurance bureau selected the local medical insurance departments. The National Medical Insurance Bureau will strengthen supervision and guidance in various forms, summarize and exchange experiences and practices and promote them in time.