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today (27th), the national medical insurance administration held a press conference on the "guiding opinions on establishing a medical insurance payment qualification management system for relevant personnel in designated medical institutions". the objects of medical insurance supervision will extend from institutions to relevant personnel. the medical insurance payment qualification management system for relevant personnel of designated medical institutions is within the framework of medical insurance agreement management, starting from the key link of medical insurance payment.implement "driver's license-style scoring" for relevant personnel of designated medical institutions to achieve dynamic and refined management.

according to the relevant person in charge of the national medical insurance administration, according to the service agreement signed between the designated medical institution and the medical insurance agency, relevant personnel involved in the use of medical insurance funds at this designated medical institution are eligible for medical insurance payment, and are also included in the scope of medical insurance supervision. mainly includes two categories:

the first category is the relevant personnel of the hospital, including medical, nursing, and technical related health professional technicians who provide services to insured persons, as well as relevant staff responsible for medical expenses and medical insurance settlement review.

the second category is the main person in charge of the designated retail pharmacy, that is, the main person in charge on the drug business license.

relevant personnel who score 12 points in a calendar year will be terminated from medical insurance payment qualifications

in the supervision of the medical insurance department,if relevant personnel are found to have violated laws and regulations, they will be scored according to the severity of the problem:

relatively minor ones will be scored with 1-3 points, more serious ones will be scored with 4-6 points, more serious ones will be scored with 7-9 points, and the most serious fraud and insurance fraud will be scored with 10-12 points.

if the score reaches 9 points in a calendar year, the medical insurance payment qualification will be suspended for 1-6 months, and the medical insurance expenses incurred for services provided during the suspension period will not be settled (except for first aid and rescue).

if the score reaches 12 points in a calendar year, the medical insurance payment qualification will be terminated, and the medical insurance expenses incurred for services provided during the termination period will not be settled. among them, if a total of 12 points is accumulated, the registration shall not be filed again within 1 year from the date of termination; if a total of 12 points are accumulated, the registration shall not be registered again within 3 years from the date of termination.

national network linkage for score processing and corresponding measures

once the medical insurance payment qualification is suspended or terminated at a designated medical institution, corresponding measures will also be taken at other designated medical institutions.if scores are processed in one region, the information will be shared across the country to achieve cross-agency and cross-regional linkage.

coupled with the linkage of the three medical institutions to form a joint regulatory force

according to the relevant person in charge of the national medical insurance administration,the medical insurance payment qualification management system will be used as an important starting point to strengthen the linkage and collaborative governance of medical insurance, medical care, and medicine.the medical insurance department will notify the health department and the drug regulatory department of the situation regarding scoring, suspension, and termination of personnel, and they will strengthen management of relevant personnel in accordance with their responsibilities and jointly form a joint regulatory force.

"one person, one file" comprehensively records compliance with laws and regulations related to medical insurance

thinking in the long run,the medical insurance department will establish "one person, one file" medical insurance integrity files for relevant personnel of designated medical institutions.everyone will receive a unique identity code. this code is like a personal id card in the national medical insurance system. it is unique for life and does not change with the household registration address or residential address. each person will also have his or her own medical insurance integrity file, which comprehensively records his or her scorekeeping status and other compliance with medical insurance-related laws and regulations, accompanying them throughout their career.

effectively curb the abuse of medical insurance funds by establishing a medical insurance payment qualification management system

the relevant person in charge of the national medical insurance administration said that in the past supervision work, the inability to accurately supervise people was a prominent problem faced by the medical insurance department. medical insurance has investigated and dealt with a large number of cases of violations of laws and regulations. since it can only deal with institutions, there are no good means for individuals who violate laws and regulations. especially in some cases of fraud and insurance fraud, the cost for individuals to violate laws and regulations is low, and only the institutions are dealt with. these people are not hurt, and some people just change their appearance and go back to their old business. the medical insurance payment qualification management system extends the supervision objects from designated medical institutions to medical staff and pharmacy operation and management personnel, truly realizing "supervision to the individual", which will greatly improve the accuracy and deterrence of medical insurance fund supervision.

at the press conference, the relevant person in charge of the national medical insurance administration also introduced that since the beginning of this year, national unannounced inspections have covered all provinces across the country, inspecting 500 designated pharmaceutical institutions, and found suspected violations of 2.21 billion yuan. among them, according to the big data model clues, 185 designated medical institutions have carried out special unannounced inspections based on the "four nos and two straights", and 810 million yuan of suspected violations were found, and 111 institutions were found to be fraudulent and fraudulent. from january to august this year, medical insurance departments at all levels across the country recovered a total of 13.66 billion yuan in medical insurance funds.

this year's medical insurance fund supervision work will pay more attention to the systemic, holistic and collaborative nature of supervision, actively explore innovative supervision methods, and strive to establish and improve a long-term mechanism for medical insurance fund supervision. in recent years, the supervision of medical insurance funds has been continuously intensified, but the illegal use of medical insurance funds by designated medical institutions is still repeatedly investigated and banned. the traditional supervision model can only punish medical institutions and cannot "supervise and punish people". important reasons. this traditional supervision model not only emboldens a small number of people who violate laws and regulations, but is also unfair to those who comply with laws and regulations. by establishing a medical insurance payment qualification management system, the regulatory reach is extended to specific responsible persons, and those responsible for violations are scored and managed, which highlights the accuracy of supervision, allows violators to pay their due price, and can effectively curb the abuse of medical insurance funds.

(cctv reporter zheng yizhe and shi yilong)