The medical insurance fund is the people’s "medical money" and "life-saving money", and the CPC Central Committee and the State Council attach great importance to the safety of the medical insurance fund.
Before the end of this year, the national intelligent monitoring "one network" will be initially realized-the Notice on Further Deepening the Intelligent Audit and Monitoring of Medical Insurance Funds issued by the National Medical Insurance Bureau (hereinafter referred to as the "Notice") proposes to accelerate the intelligent audit and monitoring of medical insurance funds, implement real-time dynamic intelligent monitoring of big data, build a fund safety prevention and control mechanism that is supervised before, during and after the event, and further weave the fund supervision and control network.
Strengthen the real-time dynamic tracking of the use behavior of medical insurance funds
At present, the supervision of medical insurance fund is faced with many supervision objects, huge amount of funds and massive settlement data. The past tactics of people’s sea, manual audit and manual supervision can no longer meet the needs of the new situation. The relevant person in charge of the National Medical Insurance Bureau said that it is very necessary to comprehensively establish an intelligent monitoring system, promote the normalization of intelligent monitoring, and strengthen the real-time dynamic tracking of the use of medical insurance funds. Intelligent audit and monitoring of medical insurance funds is an essential tool for daily audit and settlement of medical insurance departments, an important means for supervision of medical insurance funds in the information age, and an important technical support for effectively protecting people’s "medical expenses".
It is understood that the progress of the construction and application of intelligent supervision subsystem in different places is uneven, and the application results are quite different. The application progress of the national version 1.0 intelligent audit and monitoring knowledge base and rule base (hereinafter referred to as "two databases") is different. It is necessary to issue the Notice, increase the work, and promote local medical insurance departments to accelerate the application of the national version 1.0 "two databases" framework system.
Accelerating the intelligent audit and monitoring work has good information conditions and business foundation. On the one hand, the national unified medical insurance information platform has been fully established. Relying on the platform, the intelligent supervision subsystem empowers and enhances the supervision work and promotes the safe, efficient and rational use of funds. On the other hand, since 2019, intelligent audit and monitoring demonstration sites have been built in 32 cities; In March 2022, the Measures for the Administration of Knowledge Base and Rule Base for Intelligent Audit and Monitoring of Medical Security Fund (Trial) was formulated and issued; In May 2023, a national unified and standardized framework system of "two databases" was formed, and it was deployed and applied in the intelligent supervision subsystem of the medical insurance information platform. All these work have laid a solid foundation for further accelerating the intelligent audit and monitoring of medical insurance funds.
By the end of 2025, the intelligent audit and monitoring system will be basically established.
The "Notice" clarifies that by the end of 2023, all regional online intelligent supervision subsystems will be co-ordinated, intelligent audit and monitoring data will be accurately uploaded to the national medical insurance information platform, comprehensive intelligent audit will be carried out, the service behavior of designated medical institutions will be standardized, and agreement handling and administrative supervision will be strengthened, and the connection between handling verification and administrative law enforcement will be realized, and the "one network" of national intelligent monitoring will be initially realized. By the end of 2025, a standardized, scientific and normalized intelligent auditing and monitoring system will be basically established, and the construction and application of "two databases", intelligent auditing and anti-fraud big data intelligent monitoring and analysis will be more mature and perfect. Informatization, digitalization and intelligence will fully empower medical insurance auditing and fund supervision, forming a normalized supervision system that handles daily auditing and on-site verification, big data analysis, and intelligent monitoring of the whole scene.
The "Notice" requires strengthening the construction and application of the "two databases". All localities are required to accurately grasp the key points of the construction of the "two databases", and give medical insurance departments at all levels full autonomy. Under the framework system of the national "two databases", combined with local realities, rules and knowledge are supplemented, and rules parameters, indicators, thresholds, application scenarios, etc. are independently set.
Intelligent supervision subsystem for encouraging the docking of designated medical institutions
The "Notice" requires that the intelligent audit and monitoring of medical insurance funds should be combined with the agreement management, and effective measures should be taken to encourage designated medical institutions to actively dock the intelligent supervision subsystem, and the docking of the system should be linked to the annual assessment of designated medical institutions. Explore policies such as reducing the frequency of on-site inspections for medical institutions that actively strengthen the application of intelligent supervision systems and carry out self-examination and self-correction. The relevant person in charge of the National Medical Insurance Bureau said that the supervision of designated medical institutions by the medical insurance department and its internal management promote each other. Intelligent audit and monitoring is only a means of supervision and inspection, which is basically to urge medical institutions to make reasonable and standardized diagnosis and treatment, and to ensure that every penny of medical insurance funds is spent on the "cutting edge" of medical treatment for the people.
For example, the pre-warning focuses on strict real-name medical treatment, standardized diagnosis and treatment behavior, standardized billing and charging, early warning of excessive prescription of drugs, and early warning fee declaration. Through identification and video surveillance, the real-name medical treatment and drug purchase system is strictly implemented to ensure that the person’s certificate is consistent. Reminding in advance can help hospitals find deep-seated problems in internal control management, medical behavior and charging methods. For the whole medical industry, it is conducive to standardizing the practice behavior, creating a clean and upright industry environment, preventing illegal expenditures of medical insurance funds, and promoting the comprehensive strength and high-quality development of hospitals.
"Overall, medical institutions can automatically remind and intercept the obvious violations of medical personnel through intelligent monitoring, and remind suspicious violations in real time." The person in charge said that at present, more and more designated hospitals actively use intelligent monitoring to realize self-examination and self-correction, reduce the occurrence of violations, and minimize being held accountable or punished afterwards. Intelligent audit and monitoring system has become the "first line of defense" for medical institutions to use medical insurance funds in a safe and standardized way.
Does the comprehensive promotion of intelligent audit and monitoring of medical insurance funds have an impact on people’s medical treatment? The person in charge said that, in general, the medical insurance department’s fund supervision work respects the clinic and does not affect the normal medical treatment. Intelligent monitoring is "insensitive" to the insured, and will not affect the normal behavior of seeing a doctor. For clear violations of laws and regulations, it is necessary to strengthen supervision and intervention, and gradually realize the automatic interception of rigid constraints on violations of laws and regulations; For problems involving medical rationality, local medical insurance departments should fully listen to the opinions and suggestions of medical institutions when demonstrating and applying the rules. After the system detects suspicious problems, it should promptly feed back to the designated medical institutions for appeal, fully listen to the complaints of medical institutions and determine whether to pay after necessary procedures such as review, collegiate bench and final review. (Reporter Sun Xiuyan)