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On November 2, the National Health Security Administration issued the “Guiding Opinions on Active Promotion” Internet + “of Medical Services and Health Insurance Payments” (hereinafter “Opinions”).
The opinion proposes that doing a good job of paying the health insurance of the “Internet +” medical service should follow the principle of “highlighting the key points and constant expansion.” Priority should be given to ensuring the need for follow-up visits and prescriptions for outpatients with chronic and special conditions, in order to significantly improve the convenience of patients on long-term medication seeking medical treatment. On the basis of the standardized development of “Internet +” medical services and the improvement of health insurance management and payment capabilities, the scope of health insurance payment has been constantly expanded.
Zhao Heng, founder of Latitude Health, a medical strategy consulting firm, told the “Daily Business News” reporter that outpatient coordination is the focus of health insurance promotion and outpatient chronic diseases are the focus of outpatient coordination. . Therefore, health insurance reimbursements for online medical services will also be paid to outpatient clinics. I bow. In the future, it will be possible to promote the reimbursement of medical insurance for common illnesses in the “Internet +” medical service.
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Adhere to the principle of consistency between online and offline
By prioritizing the need for follow-up visits and prescriptions for outpatients with chronic and special conditions, will you drive the need for follow-up visits to switch from offline to online?
In Zhao Heng’s opinion, this mainly depends on the acceptability and usability of the patient. Since chronic diseases are mainly elderly people, their use of the Internet is not universal, so services for young people with chronic diseases can be developed first.
Regarding the scope of payment for medical services, the opinion proposed that the scope of payment should be determined in accordance with local health insurance policies and the service content of designated medical institutions that provide “Internet +” medical services. The insured person’s medical examination fees and drug fees incurred in medical institutions designated by the “Internet +” medical service in the general planning area can be paid in accordance with the medical insurance regulations of the general planning area . Among them, the expenses borne by the individual can be paid by the employee’s personal health insurance account in accordance with the regulations.
In the future, the scope of health insurance payment will continue to expand. The ruling proposes that all localities can start from outpatient clinics for chronic diseases and gradually expand the scope of health insurance for “Internet +” medical services for common and chronic diseases.
Regarding the recently added “Internet +” medical service price elements declared by medical institutions, the opinions expressed that all localities must adhere to the principle of results orientation, reflecting the law of resource consumption and reasonable connection between online and offline, speed up acceptance and review, and scientifically determine the project name and service Content, price unit, charging method, etc. they provide a political basis for cooperation between institutions to develop services and distribute income. Designated medical institutions provide “Internet +” qualified medical follow-up services and charge and pay according to the prices of general outpatient clinics in public hospitals.
In general, the “Internet +” medical service health insurance payment work should adhere to the principle of “consistency online and offline”. The rulings emphasized that a fair health insurance payment policy should be implemented for online and offline medical services, maintaining a balanced level of treatment and fostering fair competition between online and offline medical institutions.
Medication delivery fees are not included in the scope of health insurance payment
Opinions support the circulation of “Internet +” follow-up prescriptions. Exploring the interconnection of prescription information outsourcing from designated medical institutions and designated retail pharmacies, and coordinating areas with conditions can rely on the unified national health insurance information platform to accelerate the implementation of functional modules related to prescription circulation of outsourcing, facilitating the circulation of “Internet +” medical service re-examination prescriptions. Explore and coordinate the mutual recognition of functional modules related to the circulation of outsourcing prescriptions between regions to achieve “more information and prescriptions, patients fewer errands.”
The ruling also made it clear that the drug costs incurred will be paid in accordance with the rules and payment policies stipulated by offline health insurance. The cost of providing drug delivery services is not included in the scope of the health insurance payment.
Zhao Heng believes that the use of the unified national health insurance information platform as a prescription circulation platform will strengthen prescription oversight and also facilitate the payment of prescription outflows by health insurance.
Regarding the health insurance settlement, the opinion holds that “Internet +” follow-up prescriptions transferred to designated retail pharmacies in this coordination area must be paid by the health insurance fund as required by the health insurance agency. and designated retail pharmacies. .
In terms of oversight, the opinions clearly strengthened the health insurance department’s rate review responsibility. Have a complete knowledge of the information on the medical treatment of the insured person and the relevant records of the review and follow-up of the medical institution. Refusing to pay fees for medical exams and fees for non-compliant drugs, and treating you according to the agreement.
In addition, it will crack down on fraud and insurance fraud in “Internet +” medical services. In the event of fraudulent insurance, the insured will suspend their eligibility to use the “Internet +” medical service, payment of medical insurance or direct settlement of medical insurance according to regulations.
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