Effective from May 1st! my country's first legal regulation in the field of medical insurance - "Regulations on the Supervision and Administration of the Use of Medical Security Funds" - Kunming Radio

Effective from May 1st! my country's first legal regulation in the field of medical insurance - "Regulations on the Supervision and Administration of the Use of Medical Security Funds" - Kunming Radio and Television Station

Recently, the State Council announced the first administrative regulation for the national medical security system, the "Regulations on the Supervision and Administration of the Use of Medical Security Funds" (hereinafter referred to as the "Regulations"), which is scheduled to come into effect on May 1, 2021. As soon as the "Regulations" were announced, they attracted great attention from designated medical institutions, designated retail pharmacies and all parties in society. From a systematic perspective, the "Regulations" have 5 chapters and 50 articles, including general provisions, fund use, supervision and management, legal responsibilities and supplementary provisions. Generally speaking, there are the following highlights:

1. Necessary requirements for maintaining fund security. In recent years, restricted by factors such as imperfect regulatory systems and imperfect incentive and restraint mechanisms, the efficiency of the use of medical insurance funds has been inefficient. High, fraud and insurance violations and violations are frequent and widespread, and the fund supervision situation is relatively severe. In order to strengthen the management of medical insurance funds and better protect the medical needs of the people, the Party Central Committee decided to establish the National Medical Insurance Bureau to unified and centralized management of medical insurance work, which alleviated the pressure of institutional irregularities in the supervision of medical insurance funds. In the past two years, the supervision of medical insurance funds has made unprecedented achievements. As a result, a large number of fraud and insurance fraud have been investigated and punished, and a high-pressure situation has initially been formed to combat fraud and insurance fraud. In 2019, the national medical security department inspected 815,000 designated medical institutions, and used methods such as interviews, orders to make corrections, recoveries, fines, etc. to deal with 264,000 medical institutions that violated laws and regulations, accounting for 32% of the inspected institutions. Recovered 11.56 billion yuan in medical insurance funds. In 2020, the national medical security department, together with the health department, inspected more than 600,000 designated medical institutions and recovered 22.31 billion yuan in medical insurance funds. After fund supervision has achieved certain results, the problem of imperfect systems has become more prominent, and there is an urgent need to accelerate the reform of the institutional system. Facing the new era, new challenges, and new missions, the first task is to comprehensively promote the legal governance of medical insurance. The first task is to improve the rule of law and legal supervision, and ensure that fund supervision is legal, compliant, fair and just. This is to implement the overall goal of comprehensively advancing the legal governance of the country. The socialist legal system with Chinese characteristics and the inevitable requirement of building a socialist legal country".

2. Clarify the supervision and management system and mechanism of the medical security fund. The "Regulations" were promulgated to clarify the supervision and management system and mechanism of the medical security fund. The first is to clarify the regulatory responsibilities of all parties and clarify that the people's governments at or above the county level should establish and improve the supervision and management mechanism for the use of medical security funds and the fund supervision and management law enforcement system. Clarify that medical security departments at or above the county level and other relevant departments perform their duties in accordance with the law, strengthen coordination and cooperation, and do a good job in the supervision of medical security funds. The second is to clarify that the country has established and improved a unified national medical security management system, requiring the provision of standardized and standardized medical security management services to achieve full coverage of provinces, cities, counties, towns (streets), and villages (communities).

3. Clarify the concept of social governance. First, the "Regulations" clarify that the supervision and management of medical security funds shall implement a combination of government supervision, social supervision, industry self-discipline and personal trustworthiness; the state encourages and supports the news media Carry out public welfare propaganda on medical security laws, regulations and medical security knowledge, and conduct public opinion supervision on the use of medical security funds. The second is to require people's governments at or above the county level and their medical security and other administrative departments to listen to the opinions of deputies to the National People's Congress, members of the Chinese People's Political Consultative Conference, representatives of insured persons, etc. on the use of medical security funds through written solicitation of opinions, convening symposiums, etc.; and to unblock social supervision. channels to encourage and support all aspects of society to participate in the supervision of the use of medical security funds. Third, medical institutions and pharmaceutical operating units must strengthen industry self-discipline, standardize pharmaceutical service behaviors, promote industry standards and self-discipline, and guide the legal and rational use of medical security funds. Fourth, it is clarified that the results of supervision and inspection of the use of medical security funds will be announced to the public on a regular basis, the exposure of illegal cases of use of medical security funds will be increased, social supervision will be accepted, the channels for reporting and complaints will be unblocked, and whistleblowers will be rewarded in accordance with relevant national regulations for reports that are verified to be true. .

4. Strengthen the main responsibilities of designated medical institutions and insured persons. First, designated medical institutions are required to establish and improve internal management systems, have specialized agencies or personnel responsible for the use and management of medical security funds, and organize and implement relevant systems and policies. Training, regular self-examination and self-correction of the use of medical security funds. The second is to require designated medical institutions to provide reasonable and necessary medical services in accordance with diagnosis and treatment standards to ensure that the fees paid by the medical security fund comply with the prescribed payment range. The third is to require designated medical institutions to keep relevant medical records and other information in accordance with regulations and report the information required for supervision to the medical insurance department. Fourth, insured persons should use their own medical insurance certificates to seek medical treatment, purchase medicines, and enjoy medical insurance benefits in accordance with regulations.

5. Strengthen the supervision and management methods of medical security funds. First, clearly implement multiple forms of supervision and management systems, including special inspections, joint inspections, etc. 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 management of the entire process of using shared data to ensure the security of shared data. The third is to clearly establish a credit management system for designated medical institutions and personnel, conduct hierarchical and classified supervision and management based on credit evaluation registration, and implement punishments in accordance with relevant national regulations.

6. Increase the supervision and punishment of medical security funds (1) The types of illegal acts committed by designated medical institutions have increased compared with the "Social Insurance Law". It is particularly worth mentioning that the illegal acts included in the penalties for the "Social Insurance Law" mainly include social insurance agencies and social insurance service agencies such as medical institutions and pharmaceutical business units that use fraud, forged certification materials or other means to defraud social insurance fund expenditures. Behaviors and defrauding social insurance benefits through fraud, forging certification materials or other means. The "Regulations" have added seven new behaviors that cause losses to medical security funds in designated medical institutions, including hospitalization, hanging bed hospitalization, excessive diagnosis and treatment in violation of diagnosis and treatment standards, excessive inspections, and drug exchange, to be included in administrative penalties. (2) For designated medical institutions that violate relevant regulations, the designated medical institutions are ordered to suspend the legal liability of the relevant responsible departments for not less than 6 months but not more than 1 year from medical services involving the use of medical security funds; for insured persons who violate relevant regulations, set up It has been stipulated that legal responsibilities such as online settlement of medical expenses for insured persons will be suspended for 3 months to 12 months. (3) Introduce the administrative "double penalty system" and implement "penalty-specific penalties". In the past, the "Social Insurance Law" punished designated medical institutions for fraud and defrauding insurance. The "Regulations" made a breakthrough by stipulating that individuals should be prohibited from practicing for a certain period of time if the unit violates the law. That is, the designated medical institutions violated the provisions of the "Regulations", resulting in medical insurance If the fund suffers heavy losses or other serious adverse social impacts, its legal representative or principal person in charge shall be prohibited from engaging in management activities of designated medical institutions within five years, and shall be punished by relevant departments in accordance with the law. The promulgation and implementation of the "Regulations" is a new journey for the legalization of medical security fund supervision. It will help us standardize the use of medical security funds, consolidate the overall positive trend of my country's medical security fund supervision, and promote the continuous improvement of the efficiency of medical security fund supervision. At the same time, it will also form a strong deterrent to illegal and criminal activities that cause losses to medical security funds, enhance the awareness of the main responsibilities of designated medical institutions and insured persons, improve the security and coordination of medical security funds in society, and protect people's health. Safety.