First, the inevitable requirement of maintaining the security of the fund.
In recent years, due to the imperfect supervision system, imperfect incentive and restraint mechanism and other factors, the use efficiency of medical insurance funds is not high, and fraudulent insurance and illegal behaviors are frequent and common, and the fund supervision situation is even more severe. In order to strengthen the management of medical insurance funds and better protect the people's medical needs, the CPC Central Committee decided to set up the National Medical Insurance Bureau to manage the medical insurance work in a unified way, which eased the pressure on the medical insurance fund supervision system. In the past two years, the supervision of medical insurance funds has made unprecedented progress, and a large number of fraudulent behaviors have been investigated and dealt with, initially forming a high-pressure situation to crack down on fraudulent insurance.
In 20 19, the national medical security department * * * inspected 815,000 designated medical institutions, and handled 264,000 medical institutions that violated laws and regulations, accounting for 32% of the inspected institutions, and recovered the medical insurance fund1kloc-0/560,000 yuan. In 2020, the national medical security department and the health department will inspect more than 600,000 designated medical institutions and recover the medical insurance fund of 223.438 billion yuan. After the fund supervision has achieved certain results, the problem of imperfect system is more prominent, and it is urgent to speed up the system reform. Facing the new era, new challenges and new missions, the primary task of comprehensively promoting medical insurance governance according to law is to improve the level of rule of law and supervision according to law, and ensure that fund supervision is legal, compliant, fair and just. This is an inevitable requirement for implementing the overall goal of comprehensively promoting the rule of law, that is, building a socialist legal system with Chinese characteristics and a socialist country ruled by law.
Two, a clear medical insurance fund supervision and management system and mechanism.
The promulgation of the "Regulations" clarified the supervision and management system and mechanism of medical insurance funds. First, clarify the regulatory responsibilities of all parties, and clarify that the people's governments at or above the county level establish and improve the supervision and management mechanism for the use of medical insurance funds and the fund supervision and management law enforcement system. It is clear that the medical security departments at or above the county level and other relevant departments should perform their duties according to law, strengthen coordination and cooperation, and do a good job in the supervision of medical security funds. Second, it is clear that the state has established and improved a unified national medical security management system, requiring medical security services to be standardized and standardized to achieve full coverage of provinces, cities, counties, towns (streets) and villages (communities).
Third, the concept of social governance is clarified.
First, the "Regulations" clarify that the supervision and management of medical insurance funds should combine government supervision, social supervision, industry self-discipline and personal trustworthiness; The state encourages and supports the news media to carry out public welfare publicity of medical insurance laws, regulations and medical insurance knowledge, and to supervise the use of medical insurance funds by public opinion. Second, the people's governments at or above the county level and their medical security administrative departments are required to solicit opinions in writing and hold a symposium to listen to the opinions of NPC deputies, CPPCC members and representatives of insured persons on the use of medical security funds; Smooth social supervision channels, encourage and support all sectors of society to participate in the supervision of the use of medical security funds. Third, medical institutions and pharmaceutical business units should strengthen industry self-discipline, standardize medical service behavior, promote industry norms and self-discipline, and guide the rational use of medical security funds according to law. Fourth, it is clear that the results of supervision and inspection of the use of medical insurance funds will be announced to the public on a regular basis, and the exposure of illegal cases of the use of medical insurance funds will be intensified, and social supervision will be accepted, and the channels for reporting and complaining will be unblocked. Informants will be rewarded according to the relevant provisions of the state.
Four, strengthen the main responsibility of designated medical institutions and insured persons.
First, the designated medical institutions are required to establish and improve the internal management system, with specialized agencies or personnel responsible for the management of the use of medical security funds, organize training on relevant systems and policies, and regularly check and correct the use of medical security funds. The second is to require designated medical institutions to provide reasonable and necessary medical services in accordance with the diagnosis and treatment norms, and ensure that the expenses paid by the medical security fund meet the prescribed scope of payment. The third is to require designated medical institutions to save relevant medical records and other materials in accordance with regulations, and report the information needed for supervision to the medical insurance department. Fourth, the insured person should hold his medical insurance certificate, buy medicine and enjoy medical insurance treatment according to regulations.
Five, strengthen the supervision and management of medical insurance funds.
First, clearly implement various forms of supervision and management systems, including special inspections and joint inspections. The second is to clearly establish an intelligent monitoring system, strengthen information exchange and sharing with relevant departments, establish a national unified, efficient, compatible, convenient and safe medical security information system, and implement real-time dynamic intelligent monitoring of big data. And strengthen the whole process management of * * * to ensure the data security of * * *. The third is to clearly establish a credit management system for designated medical institutions and personnel, supervise and manage according to credit evaluation and registration, and impose penalties in accordance with relevant state regulations.
Six, increase the supervision and punishment of medical insurance funds.
(1) The types of illegal behaviors in designated medical institutions have increased compared with the social insurance law. It is particularly worth mentioning that the illegal acts included in the Social Insurance Law mainly include the acts of social insurance agencies and social insurance service agencies such as medical institutions and pharmaceutical business units to defraud social insurance funds by fraud, forgery of certification materials or other means, as well as the acts of defrauding social insurance benefits by fraud, forgery of certification materials or other means. The "Regulations" will decompose seven kinds of behaviors that cause the loss of medical insurance funds, such as hospitalization, hanging bed hospitalization, excessive diagnosis and treatment in violation of medical treatment norms, excessive examination, and drug exchange, and increase them to administrative penalties.
(2) For the designated medical institutions that violate the relevant regulations, it has set legal responsibilities such as ordering the designated medical institutions to suspend the relevant responsible departments from using the medical services involved in the medical insurance fund for more than 6 months 1 year; For the insured who violates the relevant regulations, the legal responsibilities such as suspending the online settlement of the insured's medical expenses for 3 months to 12 months are set.
(three) the introduction of administrative "double penalty system", the implementation of "penalty to people". In the past, the "Regulations" made a breakthrough in prohibiting individuals from working in violation of the provisions for a certain number of years, that is, if a designated medical institution violates the provisions of the "Regulations" and causes heavy losses to the medical insurance fund or other serious adverse social impacts, its legal representative or principal responsible person will be prohibited from engaging in the management activities of designated medical institutions within five years, and the relevant departments will punish it according to law.
The promulgation and implementation of the "Regulations" is a new journey of legalization of medical insurance fund supervision, which is conducive to standardizing the use of medical insurance funds, consolidating the basic situation of improving the overall level of medical insurance fund supervision in China, and promoting the continuous improvement of medical insurance fund supervision efficiency. At the same time, it will also form a powerful shock to the illegal and criminal acts that cause the loss of medical insurance funds, enhance the awareness of the main responsibility of designated medical institutions and insured persons, improve the safety and governance capacity of medical insurance funds in the whole society, and ensure people's health and safety.