Only by insisting on grasping small things as early as possible, strictly supervising them, and preventing the whole chain of medical insurance funds from "running and leaking", can we turn passive into active.
After the implementation of the outpatient co-ordination policy, more and more qualified medical insurance designated pharmacies have been included in the scope of outpatient insurance. This provides more convenience for the insured, and also objectively increases the risk point of the use of medical insurance funds.
Not long ago, the medical insurance department found in the fund supervision work that some designated chain stores under Yixintang Pharmaceutical Group Co., Ltd. had problems such as collusion of drugs, over-prescribing of drugs, and mismatch of drug purchase, sale and inventory records. The relevant departments interviewed the relevant persons in charge of the enterprise and gave corresponding punishments. This is not an isolated case. In recent years, the use of medical insurance funds by designated pharmacies in violation of laws and regulations has occurred from time to time, and it is necessary to carefully study and judge the situation and formulate effective countermeasures.
Compared with the designated medical institutions, the scale of illegal funds involved in the current medical insurance designated pharmacies is smaller. But historical experience tells us that the embankment of a thousand miles collapses in an anthill. Only by insisting on grasping small problems as early as possible, strictly supervising, and preventing the whole chain of medical insurance funds from "running and leaking", can we turn passive into active and keep the bottom line of medical insurance fund safety.
The number of designated pharmacies for medical insurance is large and wide, which puts forward new requirements for the efficiency and accuracy of the supervision of medical insurance funds. According to the data, as of the end of August 2023, there were 1.078 million designated medical institutions nationwide, of which 484,000 were designated retail pharmacies. Most of the orders in these pharmacies are small payments, which are relatively scattered, and the number of audit documents is huge. Making good use of big data and other technical means is conducive to expanding the coverage of supervision and eliminating regulatory blind spots and blind spots. At present, the National Health Insurance Administration has built big data models such as "key drug monitoring", "false drug purchase" and "illegal resale of medical insurance drugs", accurately screened all kinds of suspicious clues and issued them to various places for verification. In some places, medical insurance departments have also developed targeted data screening models, which can identify problems more accurately and efficiently. For example, Inner Mongolia has promoted the "one-library" management and "traceability code" application of purchase, sale and inventory of designated retail pharmacies, built a big data model analysis of outpatient, inpatient and drug purchases, further clarified the rules for before, during and after the review, and intercepted violations of laws and regulations in a timely manner. Continuously innovating regulatory methods, improving regulatory efficiency, and ensuring that violations of laws and regulations have nothing to hide, can form a strong deterrent effect.
To strengthen the supervision of medical insurance funds, we must grasp the key links. Physicians and pharmacists are not only the providers of pharmaceutical services, but also the leaders of pharmaceutical service consumption. Moving the regulatory threshold forward and extending it from medical institutions to medical personnel and pharmacy directors can more effectively prevent the irrational use of medical insurance funds. In October 2023, the National Health Insurance Administration issued a draft for comments, which intends to include the relevant personnel of designated medical institutions in the medical insurance supervision objects, and the relevant responsible personnel who violate the service agreement will be disqualified from medical insurance settlement, and the prescriptions issued by them will not be reimbursed by medical insurance, and patients will need to pay for themselves. Extending the chain of supervision and "managing the pen in the hands of medical staff" undoubtedly grasps the key link and helps curb some people's non-centrific thoughts about medical insurance funds.
To maintain the safety of the medical insurance fund, it is necessary to uphold systematic thinking, build a full-process, full-field, and full-chain regulatory defense line to avoid any mistakes in any link. On the one hand, it is necessary to promote the normalization of special rectification, and promote the continuous improvement of the internal management system of designated medical institutions through unannounced inspections, interviews and warnings. On the other hand, special rectification work can be combined with credit management and other systems to further strengthen social supervision and form a joint force for governance. For example, Hefei, Anhui Province has issued relevant implementation rules to standardize the credit management of four types of entities: designated medical institutions, enterprises participating in the centralized procurement of drug consumables, pharmaceutical practitioners, and insured personnel, and expand the use of credit evaluation results, creating a good atmosphere of "everyone participates in fund supervision and jointly guards the safety of the fund".
The safe operation of the medical insurance fund is related to the vital interests of every insured. In recent years, the ecological environment for the use of medical insurance funds has been greatly improved, and "blatant" insurance fraud has been effectively curbed, but the task of preventing "leakage" is still arduous. According to the development of the situation, focusing on key and difficult points, further tightening the institutional fence, and improving the long-term mechanism, we will be able to better protect the people's "medical money" and "life-saving money".
Original title: Strictly prevent the medical insurance fund from "running and dripping"
Source | People's Daily
Edit | Yu Xinglin What to do
Hot Article
• The application of "three-way merger" in fund supervision
• Correctly understand the caliber of income data of the basic medical insurance fund for employees
• National Health Insurance Administration: Two hospitals in Henan are suspected of fraud and insurance fraud, and the medical insurance funds used in violation of regulations have been recovered