Wulian County: Create a new situation of "smart supervision"

Since the beginning of this year, Wulian County has actively explored intelligent replacement artificial audits, making full use of applications such as face recognition, medical insurance scenarios, and big data comparison, and focus on platform construction, team building, joint audit and internal control to further enhance medical insurance for medical insurance The coverage, accuracy, and effectiveness of fund supervision will build a "full -chain" closed -loop smart supervision system.

Grasping platform construction and promoting the wisdom of fund supervision

Comprehensive use of three intelligent monitoring systems and five regulatory modules to achieve the entire process of "before, events, and afterwards", "designated hospitals, clinics, pharmacies", "purchase medicine, medical, hospitalized, dialysis" throughout the process of smart supervision Essence

Comprehensive use of medical insurance intelligent monitoring platforms. The first is to strengthen the normal use of the monitoring system in the past. Take the initiative to docking with the municipal monitoring platform engineer every week, supervise and report the daily usage of the system to ensure that the hospitals end of each designated medical institution will be opened normally and effectively. The institution opens selective upload data and self -closing services. All the 20 -point hospitals in our county have taken the lead in completing the docking with the server of the Municipal Bureau, and they have achieved normal applications. The second is to strengthen post -after -data review. After the Municipal Bureau feedback the data every month, it will be issued to designated medical institutions in a timely manner to verify and defense, and resolutely refuse to pay for the illegal expenses. Since the use of the system, a total of 1301 person -times of illegal data were monitored, and 65,400 yuan of illegal funds were refused to pay the illegal fund. The third is to strengthen the intelligent audit of the face recognition module. Use face recognition modules to carry out daily audit work from time to time, focus on auditing and having to stay in bed, and take medical treatment to ensure the safety of the fund. As of now, all the designated medical institutions have access to the face recognition module, and the designated medical institutions have been hospitalized 13 times to organize the seven fixed -point medical institutions with less than 60%. Essence

Treatment of face -to -face sign -in system. In order to strongly crack down on the "fake dialysis" fraud and futile behavior, install the face -to -face sign -in system at the county people's hospital, rehabilitation hospital, and Shibei Development Zone Hospital. The hospital is required to sign in all dialysis patients. The number of patient dialysis is to prevent the occurrence of "false dialysis" through intelligent means. As of now, a total of 1144 data have been extracted, and no "false dialysis" problem was found.

Innovate the intelligent monitoring system of medical insurance scenarios. Actively explore the intelligent monitoring system of medical insurance scenarios in designated hospitals, pharmacies, and clinics to innovate and build a medical insurance scenario. By collecting data from various links such as medical treatment, purchasing medicine, and settlement, it is verified with the information association of big data personnel, compared in real time, identifies the risk of early warning in advance, realizes the process of closed -loop supervision and points early warning of the process, and fundamentally solves medical insurance. Insufficient regulatory forces, difficulty in medical insurance illegal investigation and obtaining evidence collection, and promoting the center of gravity of hospitals, pharmacies, and clinics move forward. It is planned to build 20 pharmacy systems in the first phase, and the second phase is pushed away in designated hospitals, pharmacies, and clinics.

Grasp the team building and promote the standardization of medical insurance work

Strengthen publicity and training, build 1 learning training system, 3 promotional positions, and 1 project, so that policy promotion and training "grow eyes" and "aiming direction", and continuously promote the standardization of medical insurance teams.

Build a medical insurance physician online learning training system. In order to strengthen the standardized management of medical insurance physicians in designated medical institutions, build an online learning training system, conduct medical insurance policies and tests for all medical insurance doctors in the county, and force various medical insurance doctors to be proficient in medical insurance policy The legal awareness used by institutional funds to improve the self -discipline of practice behavior. The learning method consists of two parts: usual exercise and quarterly centralized examinations, and the learning situation is included in the management of medical insurance physicians points. Chapter 5 "punishment and reward" is used. 548 medical insurance doctors have participated in the examination exam, passing 546, and the two have failed to pass the suspension of medical insurance services for 6 months.

Build the three major publicity positions of "Cloud Medical Insurance", "Medical Insurance Blue" and "Zero Medical Insurance". Implement the combination of offline and offline and offline to achieve full coverage of policy publicity. The first is the "medical insurance on the cloud" position. Strengthen the construction of the "China Wulian" government service website medical insurance sector, Douyin "Wulian Medical Insurance Micro Class", WeChat public account "Wulian Medical Security", "Smart Party Building-Medical Insurance Column" and other platforms. The "three screens" of the screen and public welfare publicity screen insert "cloud wings" to the publicity information promotion. The second is the "medical insurance blue" position. In 107 places such as the county medical insurance service hall, township and village medical insurance service stations, township convenience service center medical insurance workstations, the "medical insurance blue" layout is uniformly set up. All kinds of policies and regulations, the process of handling the process, and the standardized specifications are all eye -catching on the wall. The third is the "zero distance medical insurance" position. Formed 6 working groups, for the elderly, weak, sick and disabled, and personnel from other places to come to lotus personnel, the "go to the grassroots, talk about policies, and promote implementation" activities will be normalized. More than 5,400 people were awarded the advanced county bureaus by the Provincial Medical Insurance Bureau to regulate and propagate the publicity and propaganda work.

Implement the "6+3" project for cadre capability quality. Establish 6 capabilities: 6 as the main body to enhance the overall situation of cadre service, promote development, pay close attention to implementation, breakthroughs, emergency processes, and anticorrosive rejection. +3 "" enhance the working system and promote the comprehensive improvement of cadres and employees' capabilities. The Douyin live broadcast number "Wulian Medical Insurance Micro Class" was opened, and the person in charge of the department took turns entering the live broadcast room to preach, promoting the improvement of business capabilities. Every Wednesday at 7:30 in the evening, the medical insurance policy will be broadcast to allow the medical insurance policy to fly into the home of ordinary people. By using the new media to perform Q & A and interaction, and solve the problem of public concern at zero distance, the fund supervision has attracted the attention of the leaders of the Provincial Medical Insurance Center. Nearly 2,000 people follow the live broadcast room. Grasp internal control and promote the closed -loop of the regulatory process

Adhere to the blade inward, formulate and improve the internal control management measures, sort out the management risk points of medical insurance funds, make good use of a system and prepare a report.

Make good use of the medical insurance system in the system. Attach great importance to the application of the internal subscription system and actively docking the municipal bureau. For a while, the feedback of the internal control statistics section is summarized by the internal control statistics, and there is indeed a problem transfer and auditing department. As of now, a total of 66 feedback data and 4 transfer issues.

Establish an internal control checklist. Improve the "Rules for the Implementation of the Internal Control of the Medical Security Business of Wulian County", sort out the internal control methods, organizational control, business operation control and other aspects, prepare the "Report on the Monthly Working Month of the Medical Insurance Business", set up a review account, slowly special to outpatient clinics Disease treatment identification, on -the -job retirement, accidental injury reimbursement, new designated medical institution assessment, insurance participation base accounting, enjoying long -term care medical insurance treatment group certification and other businesses conduct random checks. , Whether the time limit for handling is exceeded, and since this year, there have been 1011 internal control review projects, and 180 problems have been found, and all of them have been rectified.

Catch data comparison and promote accuracy of audit management

Compare the data of trauma and insurance bases to promote the accuracy of fund audits.

Strengthen the reimbursement of trauma reimbursement. United public security and court departments to make good use of the three system big data comparisons and do accidental injury reimbursement data audit work. By comparing the list of accidental damage payment, the public security system traffic accident identification list, the court's civil jurisdiction and employment relationship dispute list, ensure that the overall payment of accidental damage medical expenses meets the payment regulations. Since the beginning of this year, a total of 1,526 medical expenses for accidental injury medical expenses have been included in the key audit of 4 people who have doubts, and the medical expenses payment materials, hospitalization details and injury processes on the spot are detected. Actively paid 3995.68 yuan of illegal funds, blocking the loopholes in reimbursement of accidental injuries.

Strengthen the insured base audit. Formed a special audit class to compare the amount of payment bases in the insurance insurance system and the tax declaration amount of the tax system, whether the number, base and insurance types in the key audit unit conform to policies and regulations, whether to pay in full on time, and whether the payment is publicized. A total of 211 were audited and 62 "Rectification Opinions" issued. (Correspondent Dong Haixin)

- END -