According to statistics, since 20 19, the national medical insurance bureau has organized a 130 flight inspection team to inspect 268 designated medical institutions, 56 medical insurance agencies and 40 commercial insurance companies, and found out that the amount of suspected violations was 2.772 billion yuan, accounting for 8% of the total funds recovered in the past two years. Combined with the practice of participating in flight inspection, the author believes that to carry out flight inspection supervised by medical insurance fund under the new situation, we should firmly establish systematic thinking, strictly abide by the bottom line of norms, improve professional standards, and strive to write four articles of "visible, acceptable, reliable and excellent" to further promote the quality and efficiency of flight inspection.
First, treat it correctly.
As a unilateral and profitable administrative act, flight inspection must follow the basic principles of administrative rule of law, although no direct administrative decision is made during the inspection process. In particular, the inspection subject and the inspected object should have a correct understanding of the nature of flight inspection, actively adapt to the trend of flight inspection, and jointly create a good environment conducive to the in-depth promotion of flight inspection.
From the origin, flying inspection was first applied to the inspection of stimulants in sports competitions. In 2006, China took the lead in establishing a flight inspection system in the field of drug supervision, and gradually formed a set of relatively perfect flight inspection workflow, which played an important role in investigating problems, controlling risks and deterring illegal activities. Since the establishment of the National Medical Insurance Bureau, the flight inspection in the field of medical insurance fund supervision has been organized. Through the establishment of flight inspection procedures and overall arrangements, it has guided the coordinated promotion of various provinces, autonomous regions and municipalities, and greatly enhanced the comprehensive effect of flight inspection.
From the definition, the flight inspection of medical insurance fund supervision is the supervision and inspection carried out by the medical security department on the designated medical institutions, medical insurance agencies and their staff, commercial insurance contractors and their staff, insured persons and other behaviors involving the use of medical insurance funds without prior notice. It can be seen that the subject and object of flight inspection are clear, the key is not to inform in advance, and its main characteristics are suddenness, confidentiality and shock.
From the basis, it covers entity and procedural norms, and the national level includes social insurance law, regulations on the supervision and management of the use of medical insurance funds, regulations on the supervision and inspection of medical insurance funds, the publicity system for the full implementation of administrative law enforcement in the medical insurance system, the implementation measures for the legality review system of major law enforcement decisions (for trial implementation), and the notice on the follow-up treatment of the supervision and inspection of medical insurance funds. The local level includes local medical service prices, medical insurance control policy documents and medical insurance agreements.
From the trend point of view, it is mainly reflected in "three changes": First, normalization. Since 20 19, national and provincial flight inspections have been organized continuously, achieving full coverage of provinces, autonomous regions and municipalities. Based on the grim situation of medical insurance fund supervision at present and in the future, flying inspection, as an important way to treat both the symptoms and the root causes, still plays an important role in maintaining the high pressure of supervision. The second is standardization. The Regulations on the Supervision and Administration of the Use of Medical Insurance Funds puts forward new and higher requirements for flight inspection, and it is urgent to make efforts in improving inspection procedures, refining inspection standards and standardizing inspection procedures. The third is specialization. Flight inspection is a process of finding problems by scientific and professional methods. Facing the reality that there are many objects to be supervised and the chain is long, it is inseparable from the accurate inspection by using modern information technology and the cooperation of Qi Xin, a capable professional inspection team.
Second, be careful with greetings.
Paying attention to the preparation for the inspection and seriously welcoming the inspection is the proper meaning of carrying out flight inspection. The smooth development and effectiveness of flight inspection need the strong support of local medical insurance departments and the active cooperation of the inspected objects. Specifically, it is necessary to implement the "three major tasks":
The first is full cooperation. This is the basic requirement for * * * to do a good job in flight inspection. The medical insurance department of the inspected place and the inspected object shall perform their duties in accordance with the principle of "not being offside in performing their duties, ensuring that they are not out of touch and the inspection is not disturbed". Among them, the medical insurance department needs to assist in extracting medical insurance data in time, provide local medical insurance policies and systems (including medical insurance agreements, reimbursement, fee control and other documents), and clearly contact personnel; Subjects should truthfully provide hospital data and materials (financial accounts, medical records, records of drugs and medical consumables in and out of the warehouse, descriptions of inspection equipment, etc.). ), and make preparations for on-site inspection, such as office work, inquiry, inspection, etc.
The second is benign interaction. This is a higher standard for * * * to do a good job in flight inspection. The medical insurance department in the inspected area should adhere to the principle of "participation without judgment", actively strengthen communication with the inspection team, introduce the differences of local medical insurance policies and systems, actively respond to the inquiries of inspectors, and let the inspection team fully grasp the situation; In addition, with the approval of the inspection team, the backbone of local medical insurance supervision business can be transferred to observe the flight inspection process, and the local fund supervision professionals can be trained and trained with the help of the flight inspection practice platform. The subjects should truthfully answer the questions about diagnosis, treatment and medication consulted by the subjects, make explanations according to the evidence, be scientific and responsible, strictly state the facts, avoid questions without subjectivity.
Furthermore, it is to establish reforms. This is an important requirement for * * * to do a good job in flight inspection. For the qualitative and quantitative medical insurance violations pointed out in the inspection process, the medical insurance department of the inspected place should strengthen its political responsibility, track and verify in time, carefully analyze the causes of the problems, and urge the implementation of the rectification responsibility. While checking the list of alleged problems, the investigated object should resolutely rectify and consciously put forward effective measures of "stop loss and fill leakage" to prevent "mistakes while checking"; Pay close attention to sorting out all kinds of illegal use of medical insurance funds, clarify the responsibilities of departments and personnel and the time limit for completion, and prevent "long delays and no results"; People and things that cheat against the wind should be dealt with seriously inward to prevent "teaching with management and managing instead of punishment".