The Central Discipline Inspection Commission focuses on the "Blot Eye" logic behind the "two and a half years"?

21st Century Economic Herald reporter Wu Yinggang Beijing Recently, according to the "Medical Insurance Flight Inspection Inspection Inspection Inspection Inspection Inspection Inspection Institution on the First Day" issued by the Central Discipline Inspection Commission's website, no doubt is released on the first day of the prosecution institution Discovery: On the morning of August 24th, Li Jun, a cadre of the Fund Supervision Department of the State Medical Insurance Bureau, quickly walked into the fourth meeting room of the Second Affiliated Hospital of Kunming Medical University in Yunnan Province to check the relevant points -see the cost list, the homepage of the medical case, , Look at the surgical records, look at the consumable label, find vulnerabilities and find doubts in the comparison. On the first day of the medical institution that was officially settled in the examination point, the task of the flight inspection team was "two and a half years" for the use of the medical insurance fund of the hospital.

According to the article, this flight inspection has set up a comprehensive policy guarantee group, medical group (with comprehensive group, orthopedic group, internal group group), collection group, information group, finance group and other groups, and one -on -one the hospital is determined Fang contacts, focus on different key points to conduct inspections. From the perspective of the field, this flight inspection involves orthopedic consumables including spine consumables such as nails, rods, and fusions, as well as heart medicine products such as ultrasonic high -frequency surgery integrated systems and complex surgery special knives.

Previously, on May 31st, the official website of the State Medical Insurance Bureau officially issued the "Notice of the National Medical Insurance Bureau, the Ministry of Finance, the National Health Commission, and the State Administration of Traditional Chinese Medicine on the 2022 medical security fund flight inspection work" (hereinafter referred to as the "Notice") The notification clearly required to check the hemodialysis, orthopedics, and the high -value medical consumables of a designated medical institution.

A long -term follow -up industry insider told a reporter from the 21st Century Business Herald that with the development of big data, regulators have a more comprehensive grasp of medical insurance information, and the frequency of flying inspection has become faster. And orthopedics, as a department with a large consumption of consumables, is also a key department of collection. In the future, it will also be the key inspection of the flight inspection of the medical insurance fund. Whether it is for enterprises or medical institutions "Blasty Eye" develops better.

High -value consumables into the focus of medical insurance supervision

On July 8 this year, the National Medical Insurance Fund Flight Inspection Inspection Hulong River Launch Meeting was held in Harbin, marking the official launch of the National Medical Insurance Fund Flight Examination in 2022.

The relevant person in charge of the Fund Supervision Department of the National Medical Insurance Bureau pointed out that it is necessary to fully understand the importance, complexity and arduousness of the supervision of the medical insurance fund, carry out a good flight inspection of the medical insurance fund in accordance with laws and regulations, and strengthen the use of flight inspection results, and strictly implement the flight inspection " Three prohibited "work requirements and" six inaccurate "work discipline.

On August 23, the National Medical Security Fund Flight Inspection Inspection in 2022 kicked off in Kunming, which will launch a 10 -day "comprehensive physical examination". Just one day later, Li Jun entered Kunming, Yunnan Province on August 24th. The fourth meeting room of the Second Affiliated Hospital of the Medical University, officially started flight inspection.

It is understood that hemodialysis, orthopedics, and cardiology are all key areas of the National Medical Insurance Fund flight inspection in 2022, and it is also a frequent place for problems such as fraud.

Among them, orthopedics is one of the "severe disaster areas". In March 2022, the National Medical Insurance Bureau jointly conducted a flight inspection of Tongji Hospital affiliated to Tongji Medical College of Huazhong University of Science and Technology. It was found that the hospital had a skewers, and the high -value medical consumables of the void orthopedic department. In 2021, other medical acts were suspected of using the medical insurance fund of 910.741 million yuan in violation of regulations.

In August 2021, according to the information of the Henan Provincial Medical Insurance Bureau, the orthopedic and orthopedic tuberculosis department of Zhengzhou Sixth People's Hospital was suspected of deceiving the expenditure of medical insurance funds in a form of fake certification materials, involving 1.74 million yuan; in January 2022, according to the Beijing Municipal Medical Insurance Bureau According to the notification, Beijing Qianhai's Hospital Hospital deceived the expenditure of social insurance funds with fraud, forged certification materials or other means, and was fined about 142 million yuan.

From the perspective of other fields, in March 2021, according to reports, two cardiologists from the Central Hospital of Pukou District, Nanjing were reportedly found that there were unreasonable diagnosis and treatment, unreasonable medication and other behaviors, and the use of medical insurance funds 400,000 yuan in violation of regulations; 2021 8th 821 8th; According to the report, according to the notification, there is a violation of medical insurance in Karaqin Lair Hematopolysis Center in Chifeng City, Inner Mongolia, and illegal acts such as unreasonable charges of Yangquan Sanyhe Hematoma, involving a violation of about 1.966 million yuan.

Medical insurance researchers Jiang Yuejie analyzed the media as an example that in orthopedic diagnosis and treatment, the problems of high -value consumables in the skewers and virtual records are frequently exposed. If the patient uses 4 consumables, the final record shows 6; It was written in 2,000 yuan; the manufacturer brands registered in the hospitalization records were not the same as the actual implantation of the patients and patients.

Why are the problems in the above field frequently? Researchers in the field of medical insurance have told the 21st Century Business Herald that orthopedic consumables are generally used in the operating room, and most of the price is higher. Patients lying on the operating table can not see which consumables are used. It is more convenient. Drugs are generally cheated through false diagnosis, prescriptions, etc.

The relevant person in charge of the Social Insurance Fund Administration of Chancheng District of Foshan has analyzed that for hemodialysis consumables, its potential patients have large bases, long treatment cycles, high number of times, high medical insurance reimbursement quota and reimbursement ratio. The method is based on the project, and the hemodialysis medical behavior has complexity and uncertainty, so the risk of fund supervision will be generated. In this case, in addition to the above -mentioned "Notice", in December 2021, the State Medical Insurance Bureau's "Management Measures for Flight Inspection (Draft for Soliciting Opinions)" issued by the State Medical Insurance Bureau also pointed Intelligent monitoring of medical security reminds that the medical insurance fund may have a major security risk, etc., the medical security administrative department may start the implementation of flight inspections.

It is understood that since the establishment of the State Medical Insurance Bureau, it has resolutely crack down on fraudulent insurance. Since 2018, special governance has been carried out for three consecutive years, with full coverage for two consecutive years. , Recover the medical insurance funds of 34.875 billion yuan. At the same time, the forging forging flight inspection was continued. In 2020, the country had accumulated 2,280 flying inspection pharmaceutical institutions, and found that the amount of violations was 9.89 billion yuan.

The flight inspection is "two and a half years back to two and a half years"

The current trend of medical insurance control fees, and increased flight inspection efforts can further standardize the use of medical insurance funds.

According to the information of the National Development and Reform Commission, although the medical insurance fund is relatively large, there are many structural problems. One -third is a personal account, and the distribution of the balance of the fund is very unbalanced. It is mainly concentrated in the provinces where some population flows into, and the concentration is still increasing. In the middle and long term, the medical insurance fund still has the pressure of balanced revenue and expenditure. As economic growth has entered high -speed high -speed, the degree of aging population continues to intensify, changes in disease spectrum, medical technology progress, etc., medical expenses continue to grow, and the growth rate of fund income is lower than the growth rate of expenditure. There is a certain pressure on long -term balance.

In addition, the medical insurance fund has recently appeared in the case of incompetence. According to the State Medical Insurance Bureau data, from January to October 2021, the basic medical insurance expenditures of urban and rural residents greater than the income, and the balance was -630 million yuan.

In this case, in addition to flight inspections, the collection of pharmaceuticals and equipment in recent years has also continued to advance. According to statistics, the average concentrated procurement of drugs in the first six batches of drugs has decreased by 53%. The average decrease was 93%, and the average price of artificial hip and knee joint was reduced by 82%. At present, the collection of spinal consumables has also entered a specific stage of advancement.

However, Xu Yucai, an expert in medical reform, pointed out to the 21st Century Business Herald that the prices of orthopedic consumables and cardiac stents have dropped sharply after collecting for collection, but the standards for medical services in many regions have not been adjusted yet, which will inevitably affect the actual income of medical institutions and medical staff. The use of high -value consumables after collection may also have problems, such as intentionally inducing patients with non -collection, high -priced varieties, which will affect the implementation of the volume procurement policy. It will become the focus of the National Medical Insurance Administration's flight inspection.

It can also be seen from the article "The first day of the news" that Ji Cai is one of the focus of this flight inspection, and the collection group of the flight inspection is set up separately. The above -mentioned "Notice" also clearly requires whether to purchase and use the national organization's collection of products as a key content for flight inspection for fixed -point medical institutions.

Moreover, the breadth of the time of this flight inspection does not only cover this year. According to the article "The first day of the news", the task of the flight inspection team is to "reverse two and a half years" for the medical insurance fund usage of the hospital. The "Notice" also shows that the flight inspection objects include designated medical institutions nationwide, county -level medical insurance agencies, etc., and the inspection time range has been on January 1, 2020.

In addition, it is worth noting that while the flight inspection is conducted, the flight inspection technology of the State Medical Insurance Bureau is also constantly being upgraded.

Zhong Chongming told the 21st Century Business Herald that the State Medical Insurance Bureau could directly investigate and deal with top -level big three hospitals to prove that the flight inspection was very determined and the method was effective. Other hospitals did not dare to have a chance. "Recently I learned that the commercial security agency assisted in the flight inspection has developed a tool called the" Flying Inspection Box ", similar to a big data toolbox, and the system of inspection was running for one night. There are doubts about the doubts. In the future, there may be a lot of tools for medical insurance flight inspection, and it has been "

It is understood that in terms of flight inspection, commercial insurance has become an important third -party force in the pilot work of the medical insurance fund supervision method in recent years.

Relevant statistics show that since 2019, the National Medical Insurance Administration has introduced commercial insurance institutions such as China Life, Health Care, Taikang Pension, China United, and Sunshine Life through bidding. 69 flight inspections found suspected illegal funds of 2.232 billion yuan.

The National Medical Insurance Bureau's relevant regulatory innovation pilot evaluation report also shows that 80 % of the 26 local pilots introduced commercial insurance institutions to participate in fund supervision, and generally achieved better results.

Although the coverage scope, coverage time and technical means of flight inspection in my country are continuously expanding and improving, there should still be many problems to be resolved.

Researchers from the China Medical Insurance Research Association analyzed that the current status of the supervision of the my country Medical Insurance Fund is not optimistic. On the one hand, the current supervision power is insufficient. From the national perspective, the lack of construction of regulators is serious. There is no regulatory agency at the county level, and compared with tens of thousands of medical insurance medical institutions, the power is disparity; on the other hand, informatization construction is relatively lagging.The supervision of the medical insurance fund shall make full use of the medical insurance big data to implement intelligent monitoring to improve the effectiveness of supervision, but in the process of specific practice, the problem of insufficient medical insurance data and the inadequate interoperability of departmental information.In addition, the current construction of the rule of law needs to be improved, and there are still problems with unclear legal duties and lack of legal system support.In actual operation, the supervision of medical insurance funds from various local governments is mainly based on various medical insurance policies, but the principles and lack of targeted policies have caused controversy on regulatory content, problems, severity, and punishment methods.Essence

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