[Follow] Affairs of the medical insurance fund!Yunnan introduced the management measures for social supervisors

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Yunnan Provincial Medical Security Bureau released

"Social Supervisor of Yunnan Medical Security Fund

Management Measures (Trial) "

Details are as follows

Article 1 In order to strengthen the supervision and management of the medical security fund, maintain the security of the fund, improve the efficiency of the fund use, and form a new pattern of supervision of medical insurance funds widely participated in all sectors of society. Laws and regulations and the "Guiding Opinions of the General Office of the State Council on Promoting the Reform of the Medical Security Fund Supervision System" (National Office [2020] No. 20) "The General Office of the People's Government of Yunnan Provincial People's Government on Promoting the Promoting Medical Security Fund Supervision System Reform Mission List "Notice" (Yunzheng Office [2020] No. 66) and other document spirit, combined with the actual situation of the province, formulate these measures.

Article 2 The social supervisor (hereinafter referred to as social supervisors) referred to in these Measures refers to people from all walks of life that publicly select or invite or invite the employment of the medical security fund through the medical security department. It is mainly selected from the representatives of the National People's Congress, a member of the CPPCC, the representative of the news media, the representatives of experts and scholars, and the participating people.

Article 3 The medical security department is responsible for organizing the selection and management of social supervisors at the same level, and guiding and organizing social supervisors at the same level to carry out supervision activities within the scope of responsibility. Responsible for the training of medical security knowledge, laws and regulations and policies for social supervisors.

Article 4 Social supervisors are determined by public selection and special hire.

(1) Public selection. The applicant voluntarily enrolled and submitted a written application based on the selection information issued by the medical security department.

(2) Special invitation. The medical security department coordinates the relevant departments and units, communities, and communities of the CPPCC, the CPPCC, and the news media. It is recommended for representatives, members and relevant staff as specially invited social supervisors.

Article 5 The appointment procedure of social supervisors

(1) The medical security department issued an announcement to the society or issued a work contact letter to the society on the news media, official website and other platforms.

(2) Submitting a written application in the way of the unit recommendation or individual self -recommendation.

(3) In accordance with Article 6 of these Measures, the medical security department is appointed by the applicant's comprehensive literacy, professional and professional experience, age structure, and style of morality of the applicant.

Once the social supervisor is hired, the medical security department is issued by the medical security department and the social supervisor certificate, and it is announced to the public. The hire period is three years, and after the expiration of the period, it will be renewed or hired separately according to the situation. During the employment period, voluntary participation in the supervision of the medical security fund and not receiving remuneration.

Article 6 The appointment conditions for social supervisors

(1) Political positions are firm, honesty and self -discipline, support the party's line, policy, and policies, and consciously abide by national laws and regulations.

(2) Care and support medical security, familiar with laws and regulations and policy systems in the fields of medical security, health and health, public welfare activities such as enthusiastic volunteer services, and strong social responsibility.

(3) Adhere to the principles, be fair, and dare to fight against the unhealthy style; strong service awareness, good at contacting the masses, and can earnestly fulfill the duties of supervisors.

(4) With the health status, comprehensive quality and ability to fulfill the responsibilities, in principle, the high school and above degree is required. At the time of employment, the age is not more than 65 years old.

(5) Good quality, no criminal punishment and other bad records.

Article 7 The work responsibilities of social supervisors

(1) Actively publicize the work situation related to fund security carried out by the relevant laws and regulations, policy documents and medical security departments.

(2) Supervisory administrative departments, medical insurance agencies, and their staff at all levels in the province supervise the administrative, work style, integrity and self -discipline of the medical security fund in accordance with the law of the medical security fund.

(3) Supervise the behavior of medical insurance agencies at all levels, medical insurance medical institutions and insured people at all levels, medical insurance institutions, and insured people use medical insurance funds, timely feedback, and the quality of medical insurance policies, strengthen medical insurance management, improve medical (drug) service quality, and quality, and the quality of medical (drug) service. Maintaining reasonable, fair, and objective work opinions and suggestions on the rights and interests of the insured.

(4) Wide understand and collect opinions and suggestions on medical security work from all walks of life, and timely report to the medical security department in a timely manner that various violations of the "Social Insurance Law of the People's Republic of China", "Regulations on the Supervision and Administration of the Medical Security Fund" and other violations of the supervision process of the supervision process. Laws and regulations, the terms of the medical insurance service agreement, and the violations of discipline, violations, and breach of contract involving medical insurance funds.

(5) According to the arrangement of the medical security department, participate in special activities such as cracking down on fraud insurance and related publicity, training, discussions and other activities, and are invited to participate in the supervision of medical insurance funds organized by the medical security department.

(6) Carry out other tasks that are conducive to the safety of medical insurance funds in accordance with laws and regulations.

Article 8 The scope and content of the supervision of social supervisors

(1) Supervision of designated pharmaceutical institutions and their staff

1. Fiction pharmaceutical services, forgery of medical documents and bills, and cheating medical security funds;

2. The replacement of hospitalization, hanging beds, and resolving hospitalization will be treated for administrative personnel who do not meet the indications for admission;

3. Through false propaganda, illegal reduction fees, cashback deductions, gifts, etc., the insured persons will be used to seek medical treatment;

4. String drugs, consumables, items, diagnosis and treatment projects, etc. fraudulent medical insurance funds;

5. Excessive examination, over -treatment, violation of the drug catalog regulations, and exceeding drug restrictions to use drugs; 6. Except for emergency, rescue, etc., if the insured person or its close relatives and the guardian agrees to provide medical services in the payment scope of the medical security fund;

7. Violation of price policies for drugs, medical consumables and medical service projects;

8. Stealing medical security identity vouchers, providing medical insurance card services for non -fixed -point pharmaceutical institutions;

9. Adopting false means such as fake and tampering with application materials has become a designated medical institution, engaged in commercial advertising and promotional activities in the name of a fixed -point medical security, or transferred the designated qualifications and transferred to other units to operate;

10. Provide false invoices for insured persons, incorporate medical expenses that do not belong to the scope of medical security into the medical security fund payment, or the medical expenses that should be affordable should be recorded in the scope of the medical security fund payment;

11. Pick up cash or change drugs for the insured persons, purchase nutritional health products, cosmetics, and daily necessities, etc., and use counterfeit, inferior, expired, failure drugs to defraud medical security funds by selling counterfeit, fakes, expires, and failure drugs.

12. Refusing to accept, pushing patients, reducing services or reducing service standards, information such as public medical expenses, cost structures and other information in accordance with regulations;

13. Other acts that violate medical security laws and regulations.

(2) Supervision of insured persons

1. Forgery for medical service bills, cheating medical security funds;

2. Transfer your medical security identity certificate to others or hold a medical security certificate with others;

3. Use the opportunity to enjoy medical security treatment to resold drugs, accept cash, physical or other illegal benefits;

4. Through the relevant information such as fake, altered, concealment, altering, destruction of medical documents, medical certification, accounting vouchers, electronic information, etc., or fictional medical service projects, they have cheated medical security funds;

5. Other acts that violate medical security laws and regulations.

(3) Supervision of medical security administrative departments, agencies and their staff

1. The staff fails to fulfill the statutory responsibilities of medical security in accordance with regulations, or violates work discipline, and does not perform service commitments;

2. In order to handle medical security treatment procedures for those who do not belong to the scope of medical security, those who pay the medical security fee in violation of the regulations;

3. The medical insurance agency has deceived medical security funds through forging, altering, concealment, modification, destroying medical documents, medical certification, accounting vouchers, electronic information, etc. to deceive the medical security fund;

4. The medical insurance agency and staff changes the base and rate of the medical insurance payment without authorization, leading to less or more medical insurance premiums;

5. There is an unfair wind or violation of laws and discipline in the administrative law enforcement and agreement management of medical security departments at all levels;

6. Other acts that violate medical security laws and regulations.

(4) Supervision on other acts of violating medical insurance policies and regulations, fraudulent insurance, etc.

Article 9 Work Discipline of Social Supervisors

(1) Social supervisors shall work within the scope of responsibilities stipulated in these Measures, consciously maintain the image of the medical insurance department, and strictly abide by relevant laws and regulations.

(2) Social supervisors must hold a supervisor's work permit when carrying out supervision activities. They must not engage in activities that are not related to the supervision of medical security fund supervision as supervisors. Accept or ask for property at work.

(3) Conservative work secrets shall not disclose the state secrets, business secrets, and personal privacy involved in the supervision work, and no processing information, case information and unsteady policy information that will not be leaked or disseminate to participate in supervision activities.

(4) When performing supervision duties, there is a stake relationship with the object of supervision. If it may affect the implementation of the supervision and implement it, it shall be avoided, and shall not use the opportunity of social supervisors to use the opportunity to vent their indignation and fight revenge.

(5) Comply with other public order, good customs and discipline regulations, and violate the provisions of national laws and regulations during the supervision process, shall be handled in accordance with relevant regulations.

Article 10 If a social supervisor has one of the following circumstances, the employment may be terminated

(1) If the provisions of Article 7 of these Measures are not fulfilled, the circumstances are serious or cause serious consequences.

(2) Those who have been punished by criminal punishment, administrative sanctions, and party discipline will be punished by administrative penalties in violation of public security laws and regulations, as well as other serious bad credit records.

(3) Personal information does not match the facts when applying for registration.

(4) Those who are not able to work as social supervisors due to personal reasons.

(5) I have submitted the application request to terminate the appointment.

(6) The employment period has not been renewed.

(7) Other reasons need to stop hiring.

Article 11 Daily management of social supervisors

(1) The medical security department strengthens the daily management of social supervisors, establishes accounts, designated a special person to contact social supervisors, collects and summarizes the opinions and suggestions of social supervisors, and timely send relevant documents, briefings and information to social supervisors.

(2) Symposiums for all social supervisors each year, summarize work, exchange experiences, and listen to the opinions and suggestions of social supervisors. If necessary, the relevant social supervisors can be organized according to the needs of the work needs to hold a special meeting.

(3) Social supervisors report and provide related clues to the behavior of suspected fraud and fraudulent medical security fund. The relevant provisions of the Fund Behavior Report Reward Implementation Rules (Trial) "are rewarded. Article 12 The supervision work carried out by relevant units and personnel shall cooperate with the supervision work carried out by the normal performance of social supervisors.

Article 13 The problems, opinions, and suggestions reflected by the medical security department on the social supervisors, and the transfer of letters, complaints, and reports transferred to the masses shall be handled in a timely manner, and the implementation and implementation of social supervisors shall be dealt with in a timely manner. If it is difficult to implement it in a timely manner for the reason, the relevant situation should be informed of the social supervisor and explained.

Article 14 These Measures are explained by the Yunnan Medical Security Bureau. During the trial period, the relevant content can be adjusted according to the actual work needs. If the state issues relevant regulations, it will be provided.

Article 15 These Measures shall be implemented from the date of announcement.

Data: Yunnan Provincial Medical Security Bureau

Informationman: Li Ying

Edit: Guo Wanting

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