Common pooling funds are: pension insurance pooling fund, medical insurance pooling fund, etc. The basic pension comes from the pension insurance pooling fund, the medical insurance reimbursement part comes from the medical insurance pooling fund, and the rest comes from the personal account.
Overall fund payment refers to the use of overall account funds to pay the insured's related medical expenses. The use of overall fund payment should comply with local medical insurance policies, including hospitals and medical institutions, reimbursement scope, deductible line and proportion.
Do not meet the relevant policies and regulations, the overall fund will not be paid, and the expenses can only be borne by individuals.
1. What is the main function of medical insurance as a whole?
The medical insurance pooling fund is mainly used to pay the outpatient and inpatient medical expenses of special diseases, which belongs to the scope of basic medical insurance payment. We can't pay the general outpatient expenses and all self-funded items, and we can't pay the medical expenses caused by illegal crimes, alcoholism, suicide, self-mutilation, work-related injuries, maternity, traffic accidents, medical accidents and other liability accidents. The medical insurance fund belongs to all insured persons, and it is stored in special accounts and earmarked for special purposes, and no unit or individual may misappropriate it. The overall fund is mainly used for medical expenses such as hospitalization of insured persons, emergency rescue in non-designated hospitals, referral from different places (hospitals), resettlement in different places, and special disease clinics.
2. What are the payment methods of the fund?
1. The patient pays directly to the hospital when seeing a doctor, and then the patient settles with the medical insurance institution;
2. Patients do not pay directly for medical treatment, and hospitals and medical insurance institutions settle accounts with each other;
3, medical insurance institutions and hospitals to adopt fixed budget management, medical insurance institutions to allocate medical expenses month by month, year-end summary.
Under normal circumstances, the fund is out of danger because it adopts the method of settlement afterwards, because the medical consumption form of medical institutions occurs in the front and the settlement is behind, which means that as the settlement itself, it has lost its ability to restrain medical behavior.
If the prepayment system is adopted, it will not lead to the risk of the fund in general. Because medical insurance institutions settle accounts and pay for medical institutions according to the predetermined index system, medical institutions provide medical services according to the requirements of the cost and demand index system provided by medical insurance institutions.
Therefore, it is usually not the fund that is in danger, but another problem that is often prone to occur, that is, insufficient medical consumption. The combined payment method is to learn from each other's strong points and combine the prepaid system with the post-paid system, so as to foster strengths and avoid weaknesses and make up for their respective shortcomings.