China-Singapore Jingwei, October 16 - The website of the National Health Insurance Administration issued a notice on standardizing the management of external prescriptions for medical insurance drugs on the 16th, which clearly states that designated medical institutions shall retain all external prescriptions (paper prescription copies) involving the insured for future reference, and the retention period shall not be less than 2 years; Designated retail pharmacies shall retain prescriptions in accordance with regulations after verification and adjustment, and regularly submit them to the regional medical insurance department for inspection, and the retention period of paper prescriptions shall not be less than 2 years.
The notice pointed out that the recent special flight inspection organized by the National Health Insurance Bureau found that some designated medical institutions and designated retail pharmacies have extensive management of prescriptions for external medical insurance drugs, and false prescriptions and excessive prescriptions have occurred repeatedly, harming the legitimate rights and interests of the insured, threatening the safety of the medical insurance fund, and it is urgent to strengthen the standardized management of external prescriptions. All localities should deeply analyze the typical cases of fraud and insurance fraud in some pharmacies in Harbin City, Heilongjiang Province, comprehensively strengthen the supervision of the whole process of prescription circulation, and severely crack down on false prescription fraud and insurance fraud.
The specific requirements of the notice are as follows:
1. Standardize prescription dispensing services for designated medical institutions
Local medical insurance departments should guide designated medical institutions to equip drugs needed for diagnosis and treatment in accordance with relevant requirements and medical insurance agreements, and where they cannot be equipped for the time being but really need to be used, they shall provide necessary prescription dispensing services for the insured and strengthen management.
In the co-ordination areas where the medical insurance electronic prescription center has been launched, the designated medical institutions shall provide prescription dispensing services through the electronic prescription center. Support the printing of electronic prescriptions into paper prescriptions, so that the elderly and other insured persons in need can go to designated retail pharmacies to purchase drugs with paper prescriptions. In areas where the medical insurance electronic prescription center has not yet been launched, the paper prescription issued by the designated medical institution must be signed by the medical insurance physician of the hospital and stamped with the special seal for external prescriptions.
Designated medical institutions shall retain all external prescriptions (paper prescription copies) involving the insured for future reference, and the retention period shall not be less than 2 years. Paper prescriptions should be printed by designated medical institutions in accordance with the standards and formats prescribed by relevant departments, and serial numbering should be carried out in the preface to ensure the uniqueness and recognizability of the prescription number.
Designated medical institutions should regularly summarize and analyze the situation of external prescriptions involving the insured, and if it is found that the prescription behavior of medical personnel is not standardized, it will be reminded, criticized and educated, and if it is found that the insured person prescribes drugs under false names, repeats drugs, overprescribes drugs or uses medical insurance reimbursement benefits to resell drugs, report to the local medical insurance department in a timely manner.
2. Strengthen the management of external prescriptions in designated retail pharmacies
When the designated retail pharmacy adjusts the prescription for the insured, it should carefully check the authenticity, legality and standardization of the prescription, approve the prescription drug information, the validity period, etc., as well as the information of the insured.
In the co-ordination area where the medical insurance electronic prescription center has been launched, the designated retail pharmacy shall download the electronic prescription of the designated medical institution through the medical insurance electronic prescription center, adjust it according to the prescription, and archive the electronic prescription for future reference. In the co-ordination area where the medical insurance electronic prescription center has not yet been launched, if the insured uses a paper prescription, the designated retail pharmacy shall retain the prescription according to the provisions after verification and adjustment, and submit it to the co-ordinating regional medical insurance department for inspection on a regular basis, and the paper prescription shall be kept for no less than 2 years.
Designated retail pharmacies shall, in accordance with the relevant provisions of the medical insurance department on drug traceability codes, apply drug traceability codes to ensure that prescription drugs can be traced.
3. Strengthen the management of the circulation of prescriptions for medical insurance drugs
In principle, the drugs sold by designated retail pharmacies with the prescriptions of the designated medical institutions in the overall planning area can be included in the payment scope of the medical insurance pooling fund if they meet the requirements, and the external prescriptions of medical institutions outside the overall planning area are not accepted for the time being.
Local medical insurance departments should conscientiously implement the requirements of the Notice of the National Medical Security Administration on Printing and Distributing the Model Medical Security Service Agreement for Designated Medical Institutions (Yibaofa [2024] No. 22), include the management of external prescriptions for medical insurance drugs into the scope of agreement management, and consolidate the management responsibilities of designated medical institutions.
The co-ordinating regional medical insurance department should strengthen the daily review of external prescriptions, regularly organize "reconciliation" between designated medical institutions and designated retail pharmacies for external prescriptions, and find problems of violations of laws and regulations, and carry out agreement handling, administrative punishment, and transfer to judicial organs in accordance with relevant regulations. Designated medical institutions with a large number of prescriptions, large amounts, or abnormal fluctuations in data should focus on strengthening policy guidance and supervision and inspection.
Fourth, accelerate the construction of electronic prescription centers
All localities should rely on the unified national medical insurance information platform, pay close attention to the deployment and application of the functions of the medical insurance electronic prescription center, connect the medical insurance agencies, designated medical institutions, and designated retail pharmacies to ensure the smooth flow of electronic prescriptions.
From January 1, 2025, designated retail pharmacies equipped with "dual-channel" drugs will be required to circulate "dual-channel" drug prescriptions through the electronic prescription center, and paper prescriptions will no longer be accepted. If it is necessary to extend the use time of paper prescriptions under special circumstances, the overall planning area shall report to the provincial medical insurance department for approval and file with the National Health Insurance Bureau, and the extension time shall not exceed 3 months. The medical insurance electronic prescription center is effectively connected with the intelligent supervision subsystem.
5. Concentrate on the special management of the use of medical insurance prescriptions
By the end of December 2024, special inspections will be carried out for outpatient chronic diseases and special diseases, prescription drugs for the outpatient "two diseases" medication mechanism for urban and rural residents, and other prescription drugs with high amounts, large costs, and high risks of fraud and insurance fraud.
Relying on big data analysis, it is necessary to check the use of large amounts of paper prescriptions, the mandatory inspection of large doses of single prescriptions, the mandatory inspection of repeated overprescriptions of the same insured, the mandatory inspection of many paper prescriptions in single designated medical institutions, and the mandatory inspection of large number of prescriptions prescribed by medical insurance physicians in key departments. Designated medical institutions and insured persons found in the inspection should be quickly investigated and dealt with in accordance with laws and regulations.
It is necessary to strengthen the health and rule of law education for the insured, resolutely crack down on the collusion of doctors and patients to defraud and defraud insurance, and comprehensively adopt methods such as credit evaluation and reducing the convenience of medical insurance services to educate and punish the insureds involved in fraud and deception, and support all localities to explore appropriate adjustments to the medical insurance benefits of the insured who have fraudulently defrauded the insurance. Where there are problems of violations of laws and regulations, the corresponding responsibility shall be pursued in accordance with law.
The notice requires that all localities should attach great importance to the importance of comprehensively strengthening the management of external prescriptions for medical insurance drugs, supervise and guide designated medical institutions and designated retail pharmacies to do a good job in the access to medical insurance electronic prescription centers and the management of external prescriptions as required, and simultaneously increase the publicity of relevant policies and the exposure of typical cases, and guide the insured to actively cooperate and form a good working atmosphere. If there is a major situation in the work, report to the National Health Insurance Bureau in a timely manner. (Sino-Singapore Jingwei APP)