Why talk about Isshindo? National Health Insurance Administration: There are typical illegal use of medical insurance funds

Collusion in the exchange of drugs, resulting in the loss of the medical insurance fund, the National Health Insurance Bureau interviewed Yixintang Pharmaceutical

On May 24, 2024, the Fund Supervision Department of the National Health Insurance Administration interviewed the relevant person in charge of Yixintang Pharmaceutical Group Co., Ltd. (hereinafter referred to as "Yixintang"). Recently, the relevant person in charge of the Fund Supervision Department answered reporters' questions on the interview.

01

Why do we need to conduct interviews?

The CPC Central Committee and the State Council attach great importance to people's livelihood and well-being, and continue to promote institutional reform in the field of medical insurance. In recent years, the state has established and improved the "dual channel" management mechanism for medical insurance negotiation drugs, incorporated designated retail pharmacies into outpatient co-ordination, and accelerated the promotion of direct settlement of cross-provincial and remote medical treatment. However, with the extensive promotion of various medical insurance policies, the supervision of medical insurance funds is also facing some new situations and new problems, some designated retail pharmacies appear false prescription, collusion of drugs, excessive prescription and other illegal use of medical insurance funds, although medical insurance departments at all levels timely investigate and deal with some illegal acts, but more urgent is the need to further consolidate the self-management of designated retail pharmacies.

The "Implementation Opinions of the General Office of the State Council on Strengthening the Normalized Supervision of the Use of Medical Security Funds" (Guo Ban Fa [2023] No. 17) stipulates that if the implementation of the regulatory policy of the medical insurance fund is not in place, there are serious problems in the supervision of the medical insurance fund or there are major risks and hidden dangers, the National Health Insurance Administration may take the means of letter inquiry or interview to supervise and guide the relevant designated medical institutions to strictly perform their main responsibilities and do a good job in the implementation of rectification.

Judging from the supervision of medical insurance funds in various places, some designated chain stores under Yixintang have more typical illegal use of medical insurance funds. Considering that Yixintang has many stores and a large amount of medical insurance funds, in order to prevent greater problems, the Fund Supervision Department of the National Health Insurance Administration interviewed Yixintang and urged it to strengthen management, standardize behavior, earnestly fulfill the main responsibility, and better maintain the safety of the medical insurance fund.

02

What do you ask of Ichishindo in the interview?

The interview pointed out that Yixintang should deeply understand the extreme importance of maintaining the safety of the medical insurance fund, fully understand that maintaining the safety of the medical insurance fund is the only way for pharmaceutical retail enterprises to achieve their own long-term sustainable development, effectively enhance the sense of urgency and responsibility for the legal and compliant use of the medical insurance fund, and fully implement the requirements of laws, regulations and various regulations. It is necessary to take this interview as an opportunity to comprehensively strengthen rectification and reform. First, it is necessary to strengthen ideological understanding, effectively regard compliance management as the lifeline of enterprise development, and strengthen employee law-abiding education and daily management. Second, it is necessary to improve the internal control system, take the case as a reference, analyze the reasons, and carry out management constraints from the system. Third, we must carry out self-examination and self-correction, take the initiative to return the medical insurance fund used in violation of laws and regulations, and strengthen self-discipline management. Fourth, we should take the initiative to strengthen cooperation with the local medical insurance department, actively promote the application of drug traceability code scanning, and cooperate with the credit supervision of the medical insurance department.

03

How did Yixintang respond to this interview?

The person in charge of Yixintang said that the problems pointed out in this interview are an important wake-up call for the company. In the next step, Yixintang will adhere to the problem-oriented, set up a working group in accordance with the requirements of the interview, and standardize the operation of its chain stores with substantive rectification measures.

The first is to immediately organize all companies across the country to conduct a survey of more than 10,000 stores, take the initiative to report problems, take the initiative to self-examine and self-correct, and strengthen rectification.

Second, in view of the characteristics of its stores, employees, and high turnover of retail personnel, it has strengthened its efforts in employee education, on-the-job training, store management, and corporate culture.

The third is to establish a normalized supervision and management mechanism within the enterprise, strengthen the internal control of the group headquarters over all branches, branches, regions, stores, etc., and avoid rectifying old problems and new problems.

Fourth, take the initiative to strengthen the docking with the medical insurance department, jointly strengthen the daily management of stores through cooperation and cooperation, and effectively standardize the rational use of medical insurance funds.

The relevant person in charge of Yixintang said that in accordance with the requirements of the interview, before the end of June, a rectification report will be submitted to the Fund Supervision Department of the National Health Insurance Administration.

04

What are the common problems in the use and management of medical insurance funds in designated retail pharmacies?

From the perspective of the supervision practice of medical insurance funds, some designated retail pharmacies use medical insurance funds in violation of laws and regulations, mainly in the following situations:

The first category is false prescription of drugs. In the case of not genuinely purchasing and selling drugs, fabricating or forging drug prescriptions or sales records and swiping the medical insurance code (social security card) to defraud the medical insurance fund.

The second category is the exchange of drugs. The first is to replace non-drugs with medical insurance drugs, and use medical insurance funds to "pay" for health products, food, cosmetics, etc. The second is to replace non-medical insurance drugs with medical insurance drugs. The third is to replace low-priced drugs with high-priced drugs.

The third category is over-prescribing. The first is to sell drugs that are not needed or obviously exceed their dosage needs to the insured through buying, freeing, etc. The second is to provide convenience for drug dispensers (such as pharmaceutical company sales personnel, etc.) to over-prescribe and carry out medical insurance settlement, so as to facilitate their resale and promotion of drugs at low prices. The third is to induce the insured to use the employee medical insurance outpatient co-ordination fund at the end of the year to purchase drugs and consume at the top.

The fourth category is to settle medical insurance for other pharmacies. Lend the medical insurance settlement system to non-medical insurance designated retail pharmacies or designated retail pharmacies that have been suspended from medical insurance settlement, and carry out medical insurance settlement on their behalf.

The fifth category is management issues. For example, the sale of prescription drugs without a prescription, the sale of drugs before the prescription, and the mismatch of drug purchase, sale and inventory records.

05

How should designated retail pharmacies legally and reasonably regulate the use of medical insurance funds?

The Regulations on the Supervision and Administration of the Use of Medical Security Funds (Decree No. 735 of the State Council), the Interim Measures for the Administration of Designated Medical Security in Retail Pharmacies (Decree No. 3 of the National Medical Security Administration), and the Guiding Opinions of the Supreme People's Court, the Supreme People's Procuratorate and the Ministry of Public Security on Several Issues Concerning the Handling of Criminal Cases of Medical Insurance Fraud put forward clear requirements for the implementation of the main responsibility of self-management by designated retail pharmacies, which can be summarized as follows:

First, the service is genuine, and it is not fake. Designated retail pharmacies shall not induce or assist others to impersonate or falsely purchase drugs, shall not forge, alter, conceal, alter, or destroy medical documents, accounting vouchers, electronic information and other relevant materials, and shall not fabricate medical service items.

In violation of this requirement, according to Article 40 of the Regulations on the Supervision and Administration of the Use of Medical Security Funds, it is a fraud and insurance fraud, and the medical insurance administrative department will order the return of the medical insurance fund losses caused by the medical insurance fund, and impose a fine of not less than 2 times but not more than 5 times the amount of fraud; At the same time, it is ordered to suspend the medical services of the designated medical institutions involving the use of the medical insurance fund for more than 6 months and less than 1 year, until the service agreement is terminated by the medical insurance agency; Where they have practice qualifications, they are to be revoked by the relevant competent departments in accordance with law.

The above acts also constitute the crime of fraud, and the relevant responsible persons may be imprisoned for this. According to the "Guiding Opinions of the Supreme People's Court, the Supreme People's Procuratorate and the Ministry of Public Security on Several Issues Concerning the Handling of Criminal Cases of Medical Insurance Fraud", if a designated medical institution (including a drug business unit) defrauds the medical security fund for the purpose of illegal possession, the personnel who organize, plan, and implement it shall be convicted and punished as the crime of fraud; where other crimes are constituted at the same time, follow the provisions for the heavier punishment at trial and sentencing. Clearly knowing that drugs purchased by medical insurance fraud are illegally purchased or sold, it is to be convicted and punished as the crime of covering up or concealing criminal gains; Instigating, instigating, or instigating others to use medical insurance to fraudulently purchase drugs, and then illegally purchase or sell them, is to be convicted and punished as the crime of fraud.

Second, strengthen management and reasonable service. The regulations on the management of real-name drug purchase shall be implemented, the medical insurance vouchers of the insured persons shall be verified, reasonable and necessary medical services shall be provided in accordance with the diagnosis and treatment specifications, and the expense receipts and relevant materials shall be truthfully issued to the insured persons. It is not allowed to decompose prescriptions, overprescribe drugs, or represcribe drugs; Do not exchange medicines; It is not allowed to facilitate the use of the opportunity to enjoy medical insurance benefits for insured persons to resell drugs, accept the return of cash or goods, or obtain other illegal benefits; Medical expenses that are not covered by the medical insurance fund shall not be included in the settlement of the medical insurance fund.

In violation of this requirement, according to Article 38 of the Regulations on the Supervision and Administration of the Use of Medical Security Funds, the medical insurance administrative department will order the return of the medical insurance fund losses caused and impose a fine of not less than 1 time but not more than 2 times the amount of the losses caused; where corrections are refused or serious consequences are caused, the designated medical institution shall be ordered to suspend the medical services involved in the use of the medical insurance fund for between 6 months and 1 year; Where other laws or administrative regulations are violated, the relevant competent departments are to handle it in accordance with law. If it involves a violation of the territorial medical insurance service agreement, the medical insurance agency shall make an agreement to deal with it.

Third, establish rules and regulations and strengthen training. Designated retail pharmacies shall establish an internal management system for the use of medical insurance funds, and specialized institutions or personnel shall be responsible for the use and management of medical security funds, and establish and improve the assessment and evaluation system. Financial accounts, accounting vouchers, prescriptions, cost details, drug entry and exit records and other materials shall be kept in accordance with the regulations, and the data on the varieties, specifications, prices, and expenses of the drugs purchased by the insured persons shall be fully and accurately transmitted through the medical insurance information system in a timely manner, and the data of drug "purchase, sales, and storage" shall be reported on a regular basis, and shall be responsible for the authenticity. It shall organize and carry out training on the relevant systems and policies of the medical insurance fund, regularly inspect the use of the medical insurance fund of the unit, and correct non-standard behaviors in a timely manner.

In violation of this requirement, according to Article 39 of the Regulations on the Supervision and Administration of the Use of Medical Security Funds, the medical insurance administrative department will order corrections and interview the relevant person in charge; where corrections are refused, a fine of between 10,000 and 50,000 RMB is to be given; Where other laws or administrative regulations are violated, the relevant competent departments are to handle it in accordance with law. If it involves a violation of the territorial medical insurance service agreement, the medical insurance agency shall make an agreement to deal with it.

In addition, if the designated retail pharmacy violates the above provisions, causing major losses to the medical insurance fund or other serious adverse social impacts, the legal person or the main person in charge will be prohibited from engaging in the management activities of the designated retail pharmacy for 5 years, and the relevant departments shall be punished according to law.

06

How will the medical insurance department further strengthen the supervision of designated retail pharmacies?

The medical insurance department will maintain a comprehensive and strict tone, take multiple measures to increase the supervision of designated retail pharmacies, and urge designated retail pharmacies to standardize their business behavior from the beginning of the use of the overall fund, and fasten the first "button" after entering the market.

The first is to intensify unannounced inspections. Since last year, the National Health Insurance Administration has included designated retail pharmacies in the scope of annual unannounced inspections, and this year it has further stepped up unannounced inspections. Not only has the proportion of spot checks increased by designated chain pharmacies, and the number of spot checks is several times that of last year, but it is also to carry out data analysis in advance, check with clues, and directly designate inspections for designated retail pharmacies with suspicious problems found in big data screening.

The second is to improve the effect of special rectification. The medical insurance department will summarize the characteristics of illegal behaviors such as false drug purchase and drug exchange, develop targeted data screening models, and identify problems more efficiently and accurately through correlation analysis and data mining. The National Health Insurance Administration will also work with the Supreme People's Court, the Supreme People's Procuratorate, the Ministry of Public Security, the Ministry of Finance, the National Health Commission and other departments to coordinate regulatory resources and give full play to regulatory synergies to severely crack down on fraud and insurance fraud such as false drug purchases and reselling of medical insurance drugs.

The third is to continue to carry out daily supervision. Focusing on the common illegal use of medical insurance funds in designated retail pharmacies, we will carry out daily inspections and routine inspections across the country, increase the frequency of inspections, expand the scope of inspections, and strengthen supervision and deterrence. At the same time, designated retail pharmacies are encouraged to carry out self-examination and self-correction and strengthen self-discipline management.

Fourth, strengthen the application of technical means. Continue to carry out intelligent monitoring, conduct a comprehensive and automatic review of the medical insurance settlement fees of designated retail pharmacies, intercept violations of laws and regulations in a timely manner, and refuse to pay unreasonable medical insurance fund expenditures. Actively explore and promote the application of drug traceability codes in fund supervision, fundamentally avoid the secondary sale of medical insurance drugs, and put an end to the occurrence of reselling medical insurance drugs.

Fifth, establish a regulatory system to constrain them. Explore the establishment of a credit management system for the person in charge of designated retail pharmacies, and employ corresponding credit management measures for the person in charge of a designated retail pharmacy where the problem is more serious.

In the next step, the National Health Insurance Bureau will also conduct interviews with relevant institutions that have serious problems found in the inspection in combination with this year's unannounced inspection and special rectification.

It is hoped that all kinds of designated retail pharmacies at all levels across the country will correctly understand the importance of maintaining the safety of the medical insurance fund, accurately grasp the overall situation of the current comprehensive and strict supervision of the medical insurance fund, and effectively understand the role of the medical insurance system in promoting the long-term sustainable development of the drug retail industry.

Source: "National Health Insurance Administration" WeChat official account

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