National flight inspection begins
It covers eight aspects and focuses on six areas
On April 28, the National Medical Insurance Administration, the Ministry of Finance, the National Health Commission and the State Administration of Traditional Chinese Medicine jointly issued the Notice on Carrying out Flight Inspection of Medical Security Fund in 2024, covering all provinces (autonomous regions, municipalities directly under the Central Government and Xinjiang Production and Construction Corps) and all types of medical insurance fund users of the national flight inspection officially began.
The national flight inspection work is carried out in the mode of national organization, cross-province and territorial cooperation, focusing on designated medical institutions and designated retail pharmacies, and their respective key aspects of investigation and punishment are different. Compared with last year, the inspection focus of designated medical institutions and designated retail pharmacies this year is more clear, mainly:
Designated medical institutions focus on five aspects of investigation --
(一) Targeting designated medical institutions. Focus on five aspects of investigation: First, focus on serious diseasesInvestigate and punish illegal use of medical insurance funds in the fields of medicine, anesthesia, lung cancer, etc.Focus on investigating and dealing with fraud and insurance fraud. Second, focus on cardiovascular medicine, orthopedics, blood purification,Rehabilitation, medical imaging, clinical examination and other key examinations and self-examination and self-correction in the previous yearIn the field, check whether self-inspection and rectification are required. Third, targeted medical treatment for "looking back"Institutions, focusing on whether the problems found in previous annual inspections still exist and whether they are rectifiedIn place. The fourth is to focus on the network of pharmaceutical consumables, focusing on whether public medical institutions pressIt is required to purchase all required drug consumables on the provincial centralized procurement platform. Five is for the treatment of the spanProvincial remote medical patients, check whether there is illegal use of medical insurance funds.
(二) For designated retail pharmacies. Focus on three aspects of investigation: First, false purchase Medicine. Falsify prescriptions or charge lists, swipe or steal medical insurance cards or medical insurance electronic vouchers.The second is to participate in the reselling of medical insurance drugs. The third is drug swapping. To withhold payment from the health insurance fund Drugs or other commodities are exchanged into medical insurance drugs for medical insurance settlement, forging or altering medical insurance .Bills and accounts for "purchase, sale and deposit" of drugs.
The high pressure of medical insurance fund supervision has been strengthened. As early as the National Medical security Work Conference in early January this year, the National Medical Insurance Bureau stressed that the supervision of medical insurance funds should achieve comprehensive coverage of on-site supervision, accurate strikes on off-site supervision, and play a searchlight role in governance of corruption in the pharmaceutical field. Jointly with multiple departments to focus on key areas to carry out special governance, and effectively play the role of "promoting reform through investigation".
A week ago, six departments, including the National Medical Insurance Administration, the Supreme People's Court, the Supreme People's Procuratorate, the Ministry of Public Security, the Ministry of Finance and the National Health Commission, jointly issued the 2024 Special Rectification Plan for violations of laws and regulations of medical insurance funds. On April 8, the State Medical Insurance Bureau and other six departments have jointly held a special remediation meeting on violations of laws and regulations of the National Medical Insurance Fund in 2024 to deploy key work in 2024.
From the inspection object, the granularity of this national flight inspection is finer. Each province determines 2 cities as the inspected cities: first, the provincial capital; The second is to randomly select another prefecture-level city (including sub-provincial cities) within the province. Municipalities directly under the central government serve as the inspected cities.
Whether it is a designated medical institution or a designated retail pharmacy, the amount of medical insurance fund is an important factor to examine whether it is sampled.
For designated medical institutions, a comprehensive assessment of the amount of medical insurance funds and the distribution of regional medical resources, to determine the list of designated medical institutions included in the scope of national flight inspection. The flight inspection team shall randomly select or determine 2-3 designated medical institutions listed in the above list in each inspected city as the inspected institutions; If the municipality directly under the Central Government is the city to be inspected, 4-5 institutions shall be randomly selected or determined.
For the designated retail pharmacies, that is, from the top 3 designated chain pharmacies in the amount of medical insurance funds in each inspected city, one was randomly selected or identified as the inspected institution.
The same as the previous national flight inspection, this time will still take a "look back" spot check, that is, randomly selected five provinces for national flight inspection "look back". The flight inspection team randomly selected 1 designated medical institution from the above province that had received the national flight inspection in 2022 and previous years to conduct a "look back" inspection.
At the same time, clues and big data screening doubts will also be used by the National Medical Insurance Bureau in this national flight inspection, so as to directly determine the inspected city, the inspected institution and the "look back" spot inspection institution.
02
Advance flight inspection
Separate three months for rectification
Compared with last year, this year's national flight inspection start time is nearly three months ahead of schedule.
Work such as data screening, which was scheduled to start in August last year, is required to be completed in mid-early May this year. Each province shall, in accordance with the requirements of the national flight inspection, extract the relevant data of the designated medical institutions included in the scope of national flight inspection in the inspected city, complete the work of trial storage and verification, and keep it for future reference.
At the same time, according to the work arrangement, before mid-early May this year, provinces also need to organize designated medical institutions in accordance with the list of typical problems of illegal use of medical security funds by designated medical institutions in accordance with local policies, to carry out self-examination and self-correction, form a self-examination and self-correction report, and return the illegal use of medical insurance funds.
After the completion of the preliminary work, the flight inspection team will go to the inspected city to hold a national flight inspection launch meeting, organize and carry out on-site inspections, and the relevant work will be completed by the end of September.
This year's national flight inspection work still adopts the mode of "national organization, provincial cross, territorial cooperation". The national flight inspection shall implement the group leader responsibility system, and the group leader shall be the person in charge of the fund supervision work of the provincial medical insurance department, who is responsible for the specific implementation of the on-site inspection work. The group leader reasonably determines the inspectors and on-site inspection time of each group according to the work needs.
Different from the arrangement of data screening, on-site inspection and rectification work in 5 months in the previous year, the National Medical Insurance Bureau this year designated a separate 3 months after the on-site inspection to organize follow-up rectification.
According to the work arrangement, by the end of December, all localities will, in accordance with laws, regulations and policy requirements, do a good job in the follow-up verification, punishment and rectification of the national flight inspection transfer problem; The provincial medical insurance department shall submit the rectification plan to the National Medical Insurance Bureau within 30 working days after receiving the feedback of the national flight inspection results, and submit a written report within 5 working days after the completion of the case.
Finally, by the end of December, the National Medical Insurance Bureau will complete a summary of the national flight inspection work in 2024.
This year's national medical insurance flight inspection work emphasizes "strengthening the disposal and rectification", requiring the classification of violations of the nature of the treatment, the past inspection found that the problem of rectification or self-inspection and self-correction, and still repeated investigations and repeated offenders, to be severely punished; The problem of subjective and malicious fraud and insurance fraud should be severely cracked down on by a comprehensive use of judicial, administrative and agreement means.
At the same time, it is also necessary to "improve the long-term mechanism", requiring provinces to point out the typical, universal and prominent problems of national flight inspection to carry out centralized rectification throughout the province, so as to investigate and punish one, correct a batch, and standardize one piece.
Attached:
Programme of work for flight inspection of the Medical Security Fund for 2024
In order to thoroughly implement the decisions and arrangements of the Party Central Committee and The State Council, The State Council shall do the following Implementation Opinions of the Public Office on Strengthening the Regular supervision of the Use of Medical Security Funds (State Office Issue [2023] No. 17) request, the National Health Insurance Bureau in conjunction with the Ministry of Finance, the National Health The Commission and the State Administration of Traditional Chinese Medicine launched a nationwide flight inspection of the 2024 medical security fund Check (referred to as national flight inspection) and formulate this plan.
一. General requirements
The security of the medical insurance fund is the top priority, and the normalization of flight inspection is promoted and medical treatment is increased we will investigate and correct violations of laws and regulations in the field of insurance, and resolutely protect the people "Money for medical treatment" and "life-saving money". The national flight inspection adhere to the above checks and coordinate the national medical .The supervision force of the insurance fund, through the "next check level, provincial cross" mechanism, to the provincial level .It is difficult to carry out supervision and inspection at the municipal level and strive to crack the "acquaintance society and supervision at the same level" topic; Adhere to extensive coverage, to achieve all provinces (autonomous regions, municipalities directly under the central government and Xinjiang) production and Construction Corps, hereinafter referred to as the province), all types of medical insurance fund users covered,Focus on areas with large medical insurance fund revenue and expenditure and rich medical service resources districts and institutions; Adhere to random spot checks, randomly determine the inspected city and the inspected institution, strong adjust fairness and justice and alarm bells, and guide designated medical institutions to strengthen self-discipline and active regulation a surname; Adhere to the focus, focus on the masses to reflect the problem more strongly and make the medical insurance fund with the more prominent areas of problems, according to the idea of pressing stubble and solving them one by one, points batch and stage to promote the problem one by one in-depth investigation, step by step standardized solution.
二、Heck the object
(一) The city being inspected.
Each province determines 2 cities as the inspected cities: first, the provincial capital; Second, in another prefecture-level city (including sub-provincial cities) was randomly selected within each province. Municipality directly under the central government directly as the city of inspection.
(二) The organ being inspected.
1. Designated medical institutions. Comprehensive evaluation of the amount of medical insurance funds and regional medical resources The list of designated medical institutions included in the scope of national flight inspection shall be determined. The flight inspection team shall be located in the designated medical institutions listed above in each inspected city Machine selection or determination of 2-3 as the inspection institutions; Where a municipality directly under the central Government is the city to be inspected, Randomly select or determine 4-5 institutions to be inspected.
2. Designated retail pharmacies. In principle, from the health insurance fund of each inspected city One of the top 3 designated chain pharmacies was randomly selected or determined to be inspected Institution.
(三) "Retrospective" spot checks.
Five provinces were randomly selected for national flight inspection "looking back". Flight inspection team Designated medical aircraft that have received national flight inspection in 2022 and previous years from the above provinces In the construction, 1 house was randomly selected for "look back" inspection.
(四) Designated inspection.
The National Medical Insurance Bureau can screen suspicious points according to work needs or report clues and big data Etc., directly determine the inspected city, the inspected institution and the "look back" spot inspection institution.
三. Check the content
Focus on the use and management of the medical insurance fund and the construction and implementation of the relevant internal control system during the period from January 1, 2022 to December 31, 2023, if necessary Retroactive inspection of previous years or extended inspection to year 2024.
(一) Targeting designated medical institutions. Focus on five aspects of investigation: First, focus on serious diseases Investigate and punish illegal use of medical insurance funds in the fields of medicine, anesthesia, lung cancer, etc. Focus on investigating and dealing with fraud and insurance fraud. Second, focus on cardiovascular medicine, orthopedics, blood purification, Rehabilitation, medical imaging, clinical examination and other key examinations and self-examination and self-correction in the previous year In the field, check whether self-inspection and rectification are required. Third, targeted medical treatment for "looking back" Institutions, focusing on whether the problems found in previous annual inspections still exist and whether they are rectified In place. The fourth is to focus on the network of pharmaceutical consumables, focusing on whether public medical institutions press It is required to purchase all required drug consumables on the provincial centralized procurement platform. Five is for the treatment of the span Provincial remote medical patients, check whether there is illegal use of medical insurance funds.
(二) For designated retail pharmacies. Focus on three aspects of investigation: First, false purchase Medicine. Falsify prescriptions or charge lists, swipe or steal medical insurance cards or medical insurance electronic vouchers. The second is to participate in the reselling of medical insurance drugs. The third is drug swapping. To withhold payment from the health insurance fund Drugs or other commodities are exchanged into medical insurance drugs for medical insurance settlement, forging or altering medical insurance Bills and accounts for "purchase, sale and deposit" of drugs.
四. Organizational form
Adopt the mode of "national organization, cross-province and territorial cooperation" to carry out national flights Check the work.
(一) Promotion by State organizations. Led by the National Medical Insurance Bureau, Ministry of Finance, National Health The Health Commission and the State Administration of Traditional Chinese Medicine cooperated in organizing the national flight inspection. State Medical Insurance Bureau Responsible for drawing lots to determine the participating provinces, inspected provinces, "looking back" provinces and inspected cities, jointly Relevant departments shall formulate inspection plans, organize on-site inspections, urge the rectification of problems, coordinate major matters, and strengthen the guidance and supervision of the national flight inspection work. State Insurance Bureau Centralized office expenses and expert related expenses of the flight obstacle inspection team.
(二) Cross-inspection by provinces. The medical insurance department of the participating province led the formation of a flight inspection team, Consult the departments of finance, health and traditional Chinese medicine of the province to coordinate the dispatch of inspectors. nation The team leader is responsible for the flight inspection, and the team leader is supervised by the provincial medical insurance department The person in charge of the work shall be responsible for the specific implementation of on-site inspection. Group leader according to work If necessary, reasonably determine the inspectors and site inspection time of each group.
(三) The implementation of territorial cooperation. Medical insurance, finance and health in the inspected province and city Departments of health and traditional Chinese medicine shall cooperate in the preparation, organization and implementation of national flight inspection. Responsible for organizing designated medical institutions to carry out self-examination and self-correction, and make good data during on-site inspection Fetching, policy interpretation, liaison and coordination, communication and feedback. State flight inspection ended and reversed After the problem is fed, the inspected province and the inspected city are responsible for organizing follow-up disposal and rectification work in the whole country The province carried out extended verification.
五. Work arrangement
(一) Start flight inspection. Issued on the launch of the 2024 Medical Security Fund Fly Inform of inspection work, formulate inspection procedures, data extraction guidelines, and inspection technical instructions South, organize flight inspection training, complete the cross-matching of the participating provinces and the inspected provinces, and draw lots Will be inspected city and "look back" province. (To be completed by April 25, 2024)
(二) Organizing self-examination and self-correction. All provinces use them in violation of laws and regulations in accordance with designated medical institutions List of typical problems of medical security fund, combined with local policies, organize designated doctors in the jurisdiction Medical institutions carry out self-examination and self-correction, form a self-examination and self-correction report, and return illegal agents With the health insurance fund. (To be completed in mid-early May 2024)
(三) Extracting verification data. Each province shall, in accordance with the requirements of the national flight inspection, extract the relevant data of the designated medical institutions included in the scope of national flight inspection in the inspected city and complete the test Warehousing, verification and other work and keep for future reference. Provincial medical insurance bureau to provincial data extraction work Take charge. (To be completed in mid-early May 2024)
(四) Carry out on-site inspections. The flight inspection team went to the inspected city to hold a national flight Inspection kick-off meeting, organize and carry out on-site inspection. The State Medical Insurance Bureau inspected the situation of each group, Coordinate the inspection results, organize the feedback results in batches after the on-site inspection, and Transfer the information related to the national flight inspection to the medical insurance department of the inspected city. (September 2024 Finish before bottom)
(五) Organize follow-up rectification. All localities shall do a good job in accordance with laws, regulations and policies Follow-up verification, punishment and rectification of national flight inspection transfer problems. Provincial level The medical insurance department shall notify the country within 30 working days after receiving the feedback of the national flight inspection results The Family medical insurance Bureau first submitted the rectification plan, and submitted it within 5 working days after the completion of the case A written report. (To be completed by the end of December 2024)
(六) Complete the work summary. The National Medical Insurance Bureau completed the national flight inspection in 2024 Summary of the work. (To be completed by the end of December 2024)
六. Job requirements
(一) Improve ideological understanding. Under the guidance of the theory of justice, it is necessary to fully understand that the flight inspection of the medical security fund is carried out Implement the specific requirements of the decision-making and deployment of the Party Central Committee and The State Council, and maintain the security of the medical insurance fund It is of great significance to promote the high-quality development of medical and health undertakings. In accordance with Make unified arrangements, formulate implementation plans for participating in national flight inspection, strengthen organizational leadership, Strengthen coordination and cooperation, form joint efforts, and effectively and orderly promote the national flight inspection work Achieve real results.
（二）. Improving the effectiveness of law enforcement. The inspection province and the flight inspection team should strengthen the inspection personnel Staff education, management, supervision, to ensure strict law enforcement, standardized law enforcement, fair law enforcement, Law enforcement in a civilized manner. It is necessary to organize inspectors to carefully study inspection materials and accurately grasp inspection items Standard, focus and method to ensure strict law enforcement procedures and accurate inspection results. Be strict with Conduct the Code of Conduct for Flight Inspection of Medical Insurance Fund (Trial) and urge the inspectors to be conscious Observe political discipline, integrity discipline, mass discipline, confidentiality discipline, and work discipline.
（三）. Strengthen handling and rectification. It is necessary to carry out the country in a timely manner according to the requirements of laws and regulations Follow-up disposal of flight inspection, agreement, administrative and other punishments according to law and regulations, ensure Disposal and rectification in place. We must combine leniency with severity and classify violations of laws and regulations by their nature Disposal, after the problems found in the past inspection are rectified or self-checked and self-corrected, they are still repeatedly checked and repeated If they do, they shall be dealt with strictly and severely; The problem of subjective and malicious fraud and insurance fraud should be comprehensively applied Judicial, administrative, treaty and other means to crack down.
（四）. Improve long-term mechanisms. The provinces should draw a lesson from each other and target the national flight inspection The typical, universal and prominent problems pointed out were carried out in the whole province To deal with one, correct a batch, and standardize one piece. Make good use of national flight inspection As a result, we explored and carried out internal notification of typical cases, and strengthened case-by-case Promoting reform and warning education. It is necessary to carefully study the institutional obstacles behind the problem and continue to finish Improve the supervision system of medical insurance fund, weave a tight security network of medical insurance fund.
