Problems existing in medical insurance supervision

As the material basis and financial support of the whole medical insurance system, medical insurance fund, like the chancellor of the exchequer, provides a strong backing for the development of medical and health undertakings in China. Whether the medical insurance fund can be properly supervised and operated is related to whether the vital interests of each insured person can be guaranteed, and even to the long-term stability of the whole society. In the process of using medical insurance fund, it is the primary goal of medical insurance management to take reasonable measures to supervise it and consolidate its position as a "guardian" of the legitimate interests of the insured and a "provider" of more advanced medical services.

First, the current problems in the supervision of medical insurance funds

(a) medical institutions and their medical practitioners to implement medical insurance management regulations are not in place.

First, designated medical institutions overuse medical services for patients. Unreasonable examination of medical insurance patients, including no indication examination and repeated examination; Unreasonable drug use, excessive prescription and drug abuse; Unreasonable hospitalization, lowering admission standards.

Second, the charges for medical insurance patients are unreasonable. There are some phenomena in hospitals, such as over-standard charges, subdivided charges and irregular charges. Do not belong to the scope of medical insurance inspection items, material costs packaged into medical insurance settlement; If the drug price is not adjusted in time, it will be overcharged.

(two) the management of designated retail pharmacies is not in place.

First, the medical insurance violations of the insured and a few lawless elements have occurred from time to time.

Criminals collude with the insured and medical practitioners to defraud the medical insurance fund and insurance money, which greatly harms the safety of the medical insurance fund. Some insured persons lend or fraudulently use medical certificates such as medical insurance cards for personal gain, and even provide convenience for criminals to illegally sell medical insurance drugs, resulting in the loss of medical insurance funds.

Second, violation of drug sales regulations, excessive prescription, no prescription, and irregular drug management.

Two, strengthen the supervision of medical insurance funds, control the loss of funds, to ensure the safety of funds.

(1) Accelerate the legislative process and form a series of medical insurance supervision systems with legislation as the main body.

First, in view of the problems existing in medical insurance funds, study and formulate normative government documents to strengthen the management and supervision of social insurance funds, strictly implement fund management policies and regulations, and establish and improve the working system of social security supervision committees.

The second is to issue normative documents to improve medical service behavior. Corresponding regulations should be made to protect the insured's right to seek medical treatment in view of the behaviors that limit dispensing, decompose discharge, and excessive self-funded medical expenses and harm the interests of the insured.

Third, in view of the irregular behaviors of medical institutions and their medical practitioners in implementing medical insurance management regulations, formulate a long-term mechanism, improve the hierarchical management system of designated medical institutions, and establish an incentive and restraint mechanism for designated medical institutions; Study the credit management system of professional doctors and insured individuals, increase the illegal cost, especially link the illegal medical insurance behavior of medical practitioners with their professional qualifications, and promote the standardized management of medical service behavior.

(2) Improve the quality of supervisors and improve their supervisory ability.

In order to change the supervision mode of medical insurance fund and the traditional practice of relying on manual on-the-spot investigation, from expanding the scope to improving the quality, it is imperative to build "high-quality medical insurance" through continuous, systematic and standardized special training for fund supervisors with irregular employment and insufficient professional training management, build a professional supervision team, take professional training exchange as the starting point of professional construction, and strengthen practical skills training through seminars, case analysis and other forms to enhance their ability to solve practical problems.

(3) Strengthen multi-party cooperation and all-round supervision and management.

The first is to further improve the third-party evaluation and audit mechanism. Realize the organic combination of medical insurance management and medical clinical work, actively establish a medical insurance evaluation expert database, provide fair, open and reasonable judgment and technical support for the on-site evaluation and audit of medical insurance funds in designated medical institutions, improve the transparency and fairness of medical insurance work, and gradually standardize the service behavior of medical institutions. Do a good job in the coordination, solution, supervision and inspection of major problems in law enforcement supervision and audit in the operation of medical insurance funds, establish a joint meeting system composed of multiple related units, clarify the main responsibilities of the joint meeting and the responsibilities of the member units of the joint meeting, and realize the whole process and all-round supervision of the operation of medical insurance funds.

The second is to use social forces to supervise. Set up a tip-off telephone, implement the information disclosure system, strengthen public opinion propaganda, form a social atmosphere in which the whole society cares about and maintains the safety of medical insurance funds, rely on social forces to participate in supervision, set up a tip-off reward mechanism, and promote the enthusiasm of social supervision.

(four) the use of network monitoring, and constantly improve the effectiveness of medical insurance fund supervision.

Using modern information technology to improve the quality and level of medical service supervision, promote the change from post-event supervision to pre-event supervision, increase the punishment and deterrence of medical illegal acts, especially insurance fraud, and lay the foundation for scientific assessment and evaluation of medical institutions. In the actual operation process, network supervision should be combined with on-site supervision to provide the focus and direction of supervision and accurately locate suspected problems; Network supervision should be combined with doctor management, and doctors' medical service behavior should be brought into the scope of supervision through network monitoring system. If there are violations, it will be able to conduct statistics and tracking; Network supervision should be combined with medical service assessment, and network monitoring objectives should be combined with assessment requirements to make monitoring more targeted.

Third, the future work ideas

(A) improve the agreement management

Agreement management is the first line of defense for fund supervision, and it is also the most important starting point at present. It is necessary to refine the contents of the agreement, formulate personalized fixed-point service agreements for different designated medical institutions, and clarify the liability for breach of contract and the handling methods. Strict cost audit, standardize the two-level audit mechanism of preliminary examination and review, adopt the inspection methods of combining on-site inspection with off-site inspection, combining manual inspection with intelligent monitoring, and combining prior notice with surprise inspection, and comprehensively carry out supervision and inspection on the performance of the agreement by designated medical institutions. Strengthen the construction of internal control system of handling institutions, standardize the financial accounting system of funds, and resolutely plug the risk loopholes. At present, both the signing and implementation of the agreement are in danger of losing breadth and loosening. We should further improve the content of the agreement, standardize the medical service behavior, and let the agreement management run through the whole business process.

(2) Strengthen the capital supervision infrastructure.

The first is to carry out comprehensive business training. Actively participate in the training of fund directors of provincial bureau and Jiaxing bureau. Strengthen the knowledge training of fund supervision practitioners, focus on training funds supervision laws and regulations, case investigation methods, designated retail pharmacies investigation skills, standardize case handling procedures, and improve the level of law enforcement as soon as possible.

The second is to promote the construction of social organizations such as medical insurance industry associations. Find out the base number of designated medical institutions, medical insurance doctors and licensed pharmacists in pharmacies, guide the establishment of medical insurance doctors' associations, pharmaceutical associations, hospital associations and other organizations, hire medical insurance social supervisors and other forms, guide medical institutions to establish and improve the internal management system of medical insurance doctors and licensed pharmacists, and gradually form industry self-management, self-discipline and self-regulation, and play the role of social supervision.

The third is to build a credit system for fund supervision. Explore the establishment of a "blacklist" system for illegal designated medical institutions, medical insurance doctors and insured persons, incorporate serious illegal objects into the "credit Zhejiang" management system, establish a disciplinary mechanism for dishonesty, and exert the deterrent force of joint punishment, so that one violation is limited everywhere and the illegal cost is increased.

The fourth is to strengthen the internal risk prevention and control of handling institutions. In accordance with the principle of "subsection inspection, individual responsibility and mutual checks and balances", we will formulate and implement the internal control standards for medical insurance management in our city, set up the handling process, improve the internal control management of fund finance and information, and resolutely plug the risk loopholes. The handling institution comprehensively sorts out the internal control risk points of the medical insurance fund from the aspects of business operation, financial management, information system, audit and internal control, establishes a risk prevention and control ledger, and defines the risk points, prevention and control measures and responsible persons of business handling and fund use. The administrative department of medical security shall make an inspection plan every year, and employ a third-party agency to comprehensively carry out internal control inspection and internal control risk assessment on the agencies within its jurisdiction.

Fifth, do a good job in risk management and control of capital operation. Establish the operation monitoring and risk control system of medical insurance fund in our city to ensure the safety of the fund and improve its performance. In conjunction with the municipal finance, do a good job in the budget and final accounts of the medical insurance fund, correctly prepare the monthly, quarterly and annual reports of the fund, ensure that the accounts are consistent with the facts, and improve the accuracy.

(3) Strengthen positive public opinion orientation.

First, increase publicity and create a good atmosphere of public opinion. Intensify the publicity of medical security work, make overall arrangements and scientifically plan all kinds of medical security publicity activities, deepen information release and policy interpretation, promote the standardization, specialization and institutionalization of publicity work, and create a good public opinion atmosphere in which the whole society attaches importance to, cares for and supports the development of medical security.

The second is to launch a concentrated publicity month to combat fraud and insurance fraud. April was designated as the centralized publicity month to combat fraud and insurance fraud in our city. Various measures should be taken to publicize and interpret the laws, regulations and policies on the supervision of medical insurance funds, strengthen the legal awareness of designated medical institutions and insured persons, and consciously safeguard the safety of medical insurance funds.

The third is to expose typical cases of fraud and insurance fraud. It is necessary to actively announce the results of cracking down on fraud and insurance fraud through various media, and expose the typical cases of fraud and insurance fraud that have been verified, forming a deterrent effect. It is necessary to actively invite the news media and "two members and one representative" to participate in surprise inspections, unannounced visits and other activities, guide the media to form a benign interaction, and give full play to the supervisory role of news public opinion.