Heavy! Medical Insurance Bureau issued a document to monitor hospital sales of drugs

Source: National Health Insurance Bureau

Recently, the State Medical Insurance Bureau issued the "Notice on the Implementation of the "Two Pilots and One Demonstration" of the Supervision of Medical Insurance Funds". The Medical Insurance Office issued [2019] No. 17 (hereinafter referred to as the "Notice").

According to the "Notice", in accordance with the "Notice of the State Medical Insurance Administration on Doing a Good Job in the Supervision of the Medical Insurance Fund in 2019" (Medical Insurance [2019] No. 14), it is recommended by the medical insurance departments of the provinces (autonomous regions and municipalities) and approved by the National Medical Insurance Bureau. Organizing the selection, the National Health Insurance Bureau fund supervision method innovation pilot, fund supervision credit system construction pilot and medical insurance intelligent monitoring demonstration point (hereinafter referred to as "two pilots and one demonstration") list and work plan will be printed and distributed to you.

The work plan defines the objectives and tasks of the “two pilots and one demonstration”:

In the past two years, the pilot (demonstration point) regional supervision method innovation, credit system construction, intelligent monitoring work has made significant progress, forming experiences, models and standards that can be borrowed, replicated, and promoted, and promote the new supervision of medical insurance funds. breakthrough.

Pilot fund construction credit system construction pilot

Pilot areas can focus on one or more of the following pilots.

First, establish a fund supervision credit evaluation index system

Exploring the path of fund supervision credit system construction, focusing on exploring relevant standards, norms and indicator systems for fund supervision credit system construction, relevant information collection, evaluation and application of results.

The second is to establish a dynamic management mechanism for designated medical institutions.

Establish and improve the hierarchical management system of designated medical institutions and the medical insurance doctors, medical insurance pharmacist points management system, etc., explore the establishment of fixed-point medical institutions comprehensive performance evaluation, final elimination and other management mechanisms, establish a sound management system and mechanism, fulfill service agreements, regulate the rational use Medical insurance funds, performance appraisal, etc., as an important basis for the evaluation and evaluation of designated medical institutions, medical insurance physicians, and medical insurance pharmacists, the assessment results are related to budget management, inspection audit, cost settlement, and agreement management.

The third is to promote industry self-discipline

Encourage industry associations, non-public medical institutions, retail pharmacies, physicians, pharmacists and other industry associations to carry out industry norms and self-discipline construction, formulate and implement self-discipline conventions, and promote industry norms and self-discipline.

The fourth is to promote joint punishment

Actively promote the inclusion of fraudulent fraud insurance into the local credit management system, establish a disciplinary system for dishonesty, and play a joint disciplinary deterrent.

▍ medical insurance intelligent monitoring demonstration point

The demonstration area can focus on one or several of the following aspects to advance the work.

First, improve the intelligent monitoring function

In response to the new characteristics of fraudulent fraud behavior, the basic information standard library such as the medical standard catalogue, clinical guides and other clinical diagnosis and treatment knowledge bases are improved, and different rule bases, such as diagnosis and treatment norms, medical insurance policies, and authenticity of medical treatment, are further improved to improve intelligent monitoring. Coverage and precision.

The second is to enrich the intelligent monitoring dimension.

In areas where drug-related diagnostic group-related (DRG)-paid countries are piloted and areas where big data-based disease-based scores are paid, intelligent monitoring systems are used to enhance process monitoring of clinical behaviors, enriching the comparative dimension of big data analysis, and improving Monitoring effects; promote the application of new technologies such as video surveillance and face recognition, carry out timely management of drug invoicing, and improve the risk control system of medical insurance funds.

The third is to establish a provincial centralized monitoring system

Based on the national medical security information system construction pilot work, explore the unified implementation of intelligent monitoring work in the provincial centralized mode, and continuously improve the monitoring efficiency.

On June 5, the State Medical Insurance Bureau, the Ministry of Finance, the National Health and Health Commission, and the State Administration of Traditional Chinese Medicine jointly issued the Notice on the List of Pilot Cities for Payment by Country Related to Disease Diagnosis.