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Every reporter: Zhou Chengcheng Every editor: Chen Xing
Prime Minister Li Keqiang of the State Council chaired an executive meeting of the State Council on December 9.
The meeting approved the “Regulation on the supervision and administration of the use of medical security funds (draft)”, insisting on focusing on people’s health, determining the rights and responsibilities of health insurance departments, designated medical institutions and the insured personnel, and stipulating that according to the principle of convenience, the medical security services must be strengthened and be timely Liquidation and appropriation of medical insurance funds, improvement of the quality of the service, requires strengthening of social supervision and supervisionIt is strictly prohibited to defraud health insurance funds by falsifying or altering fictitious medical documents or medical services.。
The “Daily Economic News” reporter noted that from the typical cases announced by the National Health Insurance Bureau, it can be seen that falsified medical documents, false drug records, and diagnostic and treatment items are common.
The meeting emphasized that for violations of laws and regulations, by ordering the return of funds, suspension of the liquidation of health insurance, fines and revocation of the qualifications of designated medical institutions, we must increase the punishment, manage well health insurance funds and safeguarding the legitimate rights and interests of the masses in medical security.
Image Source: Xinhua News Agency
Fraud and insurance incidents happen from time to time
According to the 2019 National Health Insurance Development Statistics Bulletin issued by the National Health Insurance Administration, in 2019, the total income of the national basic health insurance fund (including maternity insurance) was 2.442.1 billion yuan, an increase of 10.2% over the previous year, accounting for about 2.5% of GDP that year. %; The total expenditure of the National Basic Health Insurance Fund (including maternity insurance) was 2,085.4 billion yuan, an increase of 12.2% over the previous year, which represents about 2.1% of the GDP that year.
Among fund expenditures, incidents of fraudulent obtaining of health insurance funds occur from time to time, putting pressure on health insurance funds.
In July of this year, among the five typical cases that were exposed in the first phase of the exposure platform of the National Health Insurance Office, there were hospitalizations for hanging the bed, false records of medical service fees, inspection reports of falsified medical records, false medical records and diagnostic and treatment items, falsified medical documents, and exchange items. Various behaviors of fraudulent obtaining of health insurance funds.
For example, Quzhou Jiu’an Cardiovascular Hospital (Co., Ltd.) defrauded 1.4244 million yuan in health insurance funds from 2017 to 2019 through false drug and medical item records, falsified medical documents, etc., due inconsistent drug purchases, sales, and storage; and irregular handling of the physical therapy record. Illegal refund of medical insurance funds of 690,800 yuan; Illegal declaration of medical security funds for retired paintings through false recordings and collusion articles for 444,600 yuan (including 99,800 yuan for medical security funds for retired paintings in this district and 344,800 yuan in different places).
In the same month, the “Guiding Opinions on the Promotion of the Reform of the Regulatory System of the Medical Security Fund” issued by the General Office of the State Council also indicated that due to the imperfect regulatory system and imperfect incentive and containment mechanisms, the use of health insurance funds is not efficient and the fund supervision situation more severe.
The medical security fund is the “health care money” and “life saving money” of the people. It is particularly important to ensure the safety of the health insurance fund and to strengthen fund oversight. The aforementioned “Rulings” also proposed to promote reform of the regulatory system. Including the comprehensive establishment of an intelligent monitoring system, the establishment and improvement of a reporting and reward system, the establishment of a credit management system, the establishment of a comprehensive supervision system, and the improvement of a social supervision system .
Increase the punishment for violations of laws and regulations.
Since the establishment of the National Health Insurance Office in 2018, it has continued to carry out special governance activities to combat the fraudulent acquisition of medical security funds, which has had a deterrent effect on attempts to violate laws and regulations.
According to the National Bulletin on the Development of National Health Safety Commitments in 2019, in 2019, health insurance departments at all levels inspected 815,000 designated medical institutions and investigated and treated 264,000 medical institutions that violated laws and regulations. Among them, 6,730 medical insurance agreements were lifted, 6,638 were administrative sanctions and 357 judicial bodies were transferred; 33,100 insured persons were treated in violation of laws and regulations, 6,595 people were suspended for settlement and 1,183 were transferred to judicial bodies; a total of 11,556 million yuan was recovered throughout the year.
In addition, in 2019, the National Health Insurance Bureau organized a total of 69 unannounced inspection teams in 30 provinces to inspect 177 designated medical institutions, and found a total of 2.232 billion yuan in alleged violations.
The executive meeting also proposed,Intensify punishments for violations of laws and regulations by ordering the return of funds, suspension of the liquidation of health insurance, fines and revocation of the qualifications of designated medical institutions, etc., to manage health insurance funds well and safeguard rights and legitimate interests of the masses in medical security.。
The reporter noted that some places have clear regulations on handling fraudulent obtaining of health insurance funds.
For example, the Chongqing Municipality issued the “Notice on how to do a good job in transferring cases of fraud and deception of medical security funds,” which stipulated that the illegal amount of fraudulent insurance cases was transferred from 5,000 yuan, and clarified that the health insurance department was transferred to the public security agency for the investigation and punishment of crimes. There are several situations, including methods such as falsification of medical documents, bills or financial statements, fictitious medical services “false hospitalization, false medical visits” and fraud of health insurance funds.
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