Guangdong provincial department of human resources and social security Guangdong Provincial Public Security Department Guangdong Provincial Department of Finance Guangdong Provincial Health and Family Planning Commission
Opinions of Guangdong Food and Drug Administration on Further Strengthening the Safety Supervision of Basic Medical Insurance Fund
Cantonese Social Regulation [2018] No.1
In recent years, the national basic medical insurance (hereinafter referred to as medical insurance) system has been continuously improved, and the level of financing and security has been steadily improved. At the same time, with the increasing number of participants, fraudulent insurance practices have occurred from time to time, and the means are more complicated and hidden, which has seriously violated the security of medical insurance funds, hindered the sustainable development of medical insurance system and damaged social integrity. In order to strengthen the supervision of medical insurance funds and crack down on illegal and criminal acts of fraudulent insurance, according to the Social Insurance Law, the Regulations on the Supervision of Social Insurance Funds in Guangdong Province and other laws and regulations, with the consent of the provincial people’s government, we hereby put forward the following opinions on further strengthening the safety supervision of medical insurance funds in the province:
First, standardize service behavior and strengthen supervision of all participants.
(A) to strengthen the supervision of medical institutions.. Provincial social insurance agencies should formulate model service agreements for medical institutions and strengthen guidance on the management of service agreements for medical institutions in the province. Local social insurance agencies should strengthen the negotiation of agreements with medical institutions and refine the contents of the agreements. Conditional areas can improve the agreements according to the types of medical institutions and implement classified management. Make full use of the audit results of the medical insurance intelligent audit monitoring system, strengthen the inspection and supervision of the implementation of the agreement of medical institutions, and link the inspection and supervision with the integrity file, annual deposit return, year-end expense settlement, total amount distribution in the following year, hierarchical management and agreement renewal. For medical institutions that violate the agreement, they should take measures such as interviews, rectification within a time limit, suspension of disbursement, refusal to pay fees, suspension of the agreement, and termination of the agreement in accordance with relevant regulations and agreements, and recover the illegal medical insurance expenses that have been paid. The human resources and social security department should reduce the total performance pay of public medical institutions with fraudulent insurance practices. Medical institutions, pharmaceutical trading units and other social insurance service institutions defraud social insurance fund expenditures by fraud, forgery of certification materials or other means, and the social insurance administrative department shall order them to return the defrauded social insurance money and impose a fine of not less than two times but not more than five times the amount defrauded. Medical institutions and pharmaceutical business units that have signed service agreements with social insurance agencies shall be held accountable by social insurance agencies in accordance with the agreement. If the circumstances are serious, the service agreements signed with them shall be terminated in accordance with relevant regulations. The directly responsible person in charge and other directly responsible personnel with professional qualifications,The administrative department of social insurance may suggest that the relevant competent department that granted its practice qualification revoke its practice qualification according to law; If a crime is constituted, criminal responsibility shall be investigated according to law.
(B) to strengthen the supervision of medical services..Establish a medical insurance physician management system, and stipulate the responsibilities and obligations of medical insurance physicians in the service agreement of medical institutions. Establish the integrity files of medical insurance doctors, encourage medical institutions to establish and improve the incentive and restraint mechanism of medical insurance doctors’ management, and link the medical insurance doctors’ compliance with medical insurance regulations with their job title evaluation and incentive performance pay, and the evaluation results of medical insurance doctors are linked with the assessment of medical institutions and the payment and settlement of medical expenses. For medical insurance physicians who violate social insurance regulations or agreements, the relevant departments shall, according to the circumstances, nature and agreement, give admonishing talks, interviews, rectification within a time limit, refuse to pay for the medical services they provide, and announce the record of dishonesty to the public. Medical insurance doctors who have been punished for violating the regulations on the management of medical insurance funds shall not declare professional title evaluation during the punishment period. When a medical insurance doctor takes advantage of his position to ask for or illegally accept patients’ property or seek other illegitimate interests in his practice, the health administrative department of the people’s government at or above the county level shall give him a warning or order him to suspend his practice for more than six months and less than one year; If the circumstances are serious, his practice certificate shall be revoked; If a crime is constituted, criminal responsibility shall be investigated according to law.
(three) to strengthen the supervision of retail pharmacies.. Provincial social insurance agencies should formulate a model service agreement for retail pharmacies and strengthen guidance on the management of service agreements for retail pharmacies in the province. Food and drug supervision departments and social insurance agencies should focus on checking the purchase and sale of drugs, the compliance of medical insurance drug sales, and whether there are behaviors such as purchasing drugs from illegal channels, selling drugs in violation of the regulations on the classification of prescription drugs and over-the-counter drugs, selling drugs beyond the scope, falsely selling drugs, and swapping drugs, and whether there are problems such as using medical insurance personal accounts to sell daily necessities and food. For retail pharmacies that violate the medical insurance fund in violation of the agreement, the social insurance agency shall handle it according to the relevant regulations and the agreement. If the circumstances are serious, the agreement shall be terminated according to law; If a crime is constituted, criminal responsibility shall be investigated according to law. Pharmaceutical trading enterprises must have true and complete purchase and sale records, and the purchase and sale records must indicate the generic name, dosage form, specification, batch number, expiration date, manufacturer, unit of purchase (sales), quantity of purchase (sales), purchase and sale price, date of purchase (sales) and other contents stipulated by the drug supervision and administration department of the State Council. For pharmaceutical trading enterprises that violate the above provisions, the pharmaceutical supervisory and administrative departments at or above the county level shall order them to make corrections and give them a warning; If the circumstances are serious, the Drug Business License shall be revoked by the original issuing and approving department.
(four) to strengthen the sense of responsibility of individual card for medical treatment.All localities should strengthen the publicity of the rights and obligations of individuals to participate in medical insurance according to law, and guide the insured to standardize medical treatment and abide by the law.
Second, optimize big data applications and promote real-time monitoring throughout the process.
(5) Strengthen the application of intelligent medical insurance audit monitoring system.Establish and improve the medical insurance intelligent audit monitoring system, monitor the whole process of medical service in real time, analyze the medical service behavior and medical expenses in multiple dimensions, establish a dynamic early warning index system and an event handling business system, support the discovery, recording, analysis and handling of abnormal behaviors, and realize the prompt in advance, monitoring and early warning in the process and tracing the responsibility afterwards. Focus on strengthening the monitoring of medical services such as chronic diseases, serious illnesses and hospitalization. Provincial social insurance agencies take the lead in formulating the intelligent audit rules and results processing procedures for medical insurance in the province. The social insurance agency can directly deal with the violations found and clearly defined by the monitoring system through the monitoring system. Promote technologies such as face recognition, and promote social insurance agencies, agreed medical institutions and retail pharmacies to log in to the system through face recognition.
(6) Give play to the big data monitoring function.Strengthen the big data analysis and judgment of medical insurance expenses, and monitor the whole process of outpatient, hospitalization and pharmacy purchase of contracted medical institutions and retail pharmacies, medical insurance doctors and insured persons. Strengthen the electronic information supervision of medical insurance drug consumables, connect the purchase and sale storage systems of medical institutions and retail pharmacies, increase the bill inquiry function, and realize the authenticity identification function of sporadic reimbursement invoices. Strengthen the supervision and application of big data, and strengthen the supervision of the implementation of various regulatory systems such as the budget of medical insurance funds and the implementation of medical service agreements, and the internal control management of agencies. Strengthen the security control of social security cards, standardize the transaction settlement process, and monitor the use of social security cards in agreed medical institutions and retail pharmacies and their fund transactions online in real time to prevent fund transaction risks.
Three, clear departmental responsibilities, strengthen joint supervision.
(seven) the implementation of social insurance agencies internal control audit responsibilities..Provincial social insurance agencies conduct guidance and spot checks on the development of medical insurance business of subordinate agencies every year. Social insurance agencies around the country should strictly implement the medical insurance handling system, strengthen the authority management of information systems, ensure that the whole process of business handling leaves traces, implement the double audit system for high-risk business sites and monitor the whole process. Intensify the audit of the implementation of service agreements and medical insurance fees by agreed medical institutions and retail pharmacies, and timely organize and verify the doubts found in online monitoring and report complaints. Establish and improve the verification mechanism of medical institutions and the return visit mechanism of insured persons, and implement the daily on-site verification of auditors. Strengthen the standardized management and clean government education of social insurance handling staff. Strictly implement the "Social Insurance Law", "Social Insurance Staff Disciplinary Provisions" and the provisions on the responsibility system for building a clean and honest government, implement the post responsibility system and accountability system, and implement regular rotation of key posts. If the masses report that the handling staff violates the social insurance regulations, they should carefully organize the verification and deal with it according to law. Social insurance agencies and their staff fail to perform their statutory duties of social insurance, fail to deposit social insurance funds into financial accounts, deduct or refuse to pay social insurance benefits on time, lose or tamper with payment records, enjoy social insurance benefits records and other social insurance data and personal rights records, and violate other social insurance laws and regulations, the social insurance administrative department shall order them to make corrections; If losses are caused to social insurance funds, employers or individuals, they shall be liable for compensation according to law;The directly responsible person in charge and other directly responsible personnel shall be punished according to law.
(8) StrengtheningResponsibilities of fund supervision of human resources and social security department.Human resources and social security departments should establish and improve the coordination mechanism of fund supervision, labor security supervision, comprehensive law enforcement and handling audit. Establish a receipt for reporting complaints and a system for identifying unreasonable medical expenses for medical insurance, standardize the procedures for filing and investigating, and increase the inspection of contracted medical institutions and retail pharmacies in combination with the distribution characteristics of cases of defrauding medical insurance funds, fully implement the "double random and one open" supervision, randomly select inspection objects, randomly select law enforcement inspectors, and disclose the inspection results to the public in a timely manner. Establish and improve the internal audit system of medical insurance fund, carry out the third-party audit of medical insurance fund, and timely rectify the problems found in the audit. The Provincial Department of Human Resources and Social Security took the lead in focusing on the risk points and outstanding problems of the medical insurance fund, and carried out special inspections on the safety of the medical insurance fund from time to time, and supervised major and complex cases.
(9) Implementing the supervisory duties of relevant departments.The financial department should do a good job in the budget and final accounts of the medical insurance fund, conduct separate accounting for the financial accounts of the medical insurance fund, supervise the income and expenditure and management of the medical insurance fund, and strengthen the supervision and inspection of the financial departments at lower levels in implementing the financial accounting system of the social insurance fund. Health and family planning departments should strengthen the supervision of the behaviors of medical institutions and medical staff, comprehensively promote the scoring system of bad practice behaviors of medical institutions and medical staff, and establish records of bad practice behaviors of medical institutions and medical staff in violation of laws and regulations; Guide medical and health institutions to carry out clinical pathway management in an all-round way, standardize the first page management of medical records, realize the unification of disease diagnosis, surgery and operation classification coding and medical service operation coding throughout the province, and scientifically control the unreasonable increase of medical expenses. Food and drug supervision departments should strengthen the supervision of pharmacies and retail pharmacies in medical institutions, focusing on the supervision and inspection of compliance with the provisions on the preservation of drug purchase and sale records and vouchers. Relevant departments should report to the public security organs and provide clues in time when they find suspected medical insurance fraud. After receiving the report, the public security organ shall promptly carry out verification, and those suspected of committing crimes shall be put on file for investigation.
(10) Strengthen departmental coordination and linkage.. Provincial and local human resources and social security, public security, finance, health and family planning, food and drug supervision and other departments should establish a joint meeting system between medical insurance fund safety supervision departments, improve the communication and coordination mechanism, carry out joint supervision and inspection, and coordinate and solve major problems in medical insurance fund safety supervision in a timely manner. At the same time, it is necessary to strengthen departmental information sharing and realize the sharing and intercommunication of information such as medical insurance, medical services, drug and consumables circulation as soon as possible. The departments of human resources and social security, health and family planning, and food and drug supervision, in particular, should establish an information exchange mechanism with public security organs to provide support for grasping evidence and identifying criminal facts. The human resources and social security departments and public security organs should further improve the channels for investigating and transferring medical insurance fraud cases, and strengthen the connection between administrative law enforcement and criminal justice. In violation of the agreement or laws and regulations to defraud the medical insurance fund, the human resources and social security department of the place where the act occurred shall make administrative punishment and administrative decision according to law; The human resources and social security department shall promptly notify in writing and hand it over to the relevant departments for disposal, and the relevant departments shall promptly handle and feedback the results.
Fourth, improve the credit system and strengthen social supervision.
(eleven) to broaden the channels of social supervision.Innovate the way of social supervision, smooth the channels for reporting complaints, establish and improve the reward system for reporting, and mobilize all social forces to participate in medical insurance supervision by establishing a medical insurance supervision expert database, organizing expert evaluation, and hiring social supervisors. Give full play to the role of the social insurance supervision committee, and organize the members of the supervision committee to participate in the special inspection of the medical insurance fund. Strengthen information disclosure, and gradually disclose the evaluation results and integrity files of agreed medical institutions and retail pharmacies. Rank the medical expenses of the agreed medical institutions and publish the ranking results regularly. Guide and standardize industry self-discipline, encourage the formation of medical insurance agreement institutions industry associations, promote the improvement of industry management norms and guidelines, support industry associations to carry out industry appraisal and urge rectification.
(twelve) the establishment of medical insurance credit system.. The establishment of the province’s intercommunication agreement medical institutions and retail pharmacies integrity file system, and gradually will agreement medical institutions and retail pharmacies, medical insurance doctors, insured units and individuals dishonesty recorded in the credit file, the serious dishonesty of units and individuals to implement key monitoring, according to the law to the public and notify the relevant departments. Local social insurance agencies should establish a credit file tracking mechanism, and set different monitoring periods according to the degree of risk for different violators. Among them, the monitoring period of agreed medical institutions, retail pharmacies and medical insurance doctors is not less than 12 months, and the monitoring period of insured units and individuals is not less than 6 months. If the monitoring period expires and there is no bad record during the period, it will be removed from the key monitoring scope.
V. Strengthen operation management and risk control, and lay a solid foundation for supervision.
(thirteen) to strengthen the management of medical insurance fund balance.Further expand the coverage of medical insurance, increase the collection of medical insurance coverage, do a good job in the verification of payment base and daily audit, and ensure that all insurance should be guaranteed and all receivables should be collected. The standard of medical insurance treatment should be adapted to the level of financing and local economic development. Under the premise of ensuring the balance of income and expenditure of medical insurance fund, the deductible line, capping line and payment ratio of medical insurance reimbursement should be set reasonably. The bank’s preferential interest rate policy will be implemented. Under the premise of ensuring safety, the balance of the medical insurance fund will be maintained and increased by taking time deposits, purchasing government bonds or conducting investment operations in accordance with state regulations.
(fourteen) to carry out actuarial management of the fund budget..Scientific preparation and strict implementation of the medical insurance fund revenue and expenditure budget, in principle, should not prepare the deficit budget of the current year, and should not prepare the accumulated balance deficit budget of the fund over the years. When compiling the budget, it is really necessary to use the accumulated balance over the years to make up for the expenditure of the current year, which shall conform to the provisions of the financial system of social insurance funds and be reported to the people’s government at the same level for examination and approval. Combined with budget management, improve the control measures of total medical insurance and promote the reform of medical insurance payment system. Local human resources, social security and financial departments should carry out long-term actuarial calculations of medical insurance funds, complete the actuarial calculations of the previous year before the end of June each year and report them to the human resources, social security and financial departments at the next higher level respectively, and improve relevant policies in a timely manner according to the reference actuarial results to ensure the actuarial balance of the funds.
(fifteen) to strengthen the fund risk early warning and risk point supervision.Carry out the safety assessment of medical insurance funds in the whole province, strengthen the identification, judgment, early warning and handling of medical insurance fund risks, improve the operational analysis, risk judgment and early warning response mechanism of medical insurance funds, scientifically set warning lines of various risk levels, implement risk grading monitoring and early warning, and immediately start the risk early warning response mechanism once risks are discovered. Comprehensively sort out the risk points of medical insurance fund operation, and strengthen risk prevention and control of social insurance agencies’ medical insurance treatment conditions review and payment, medical insurance fund settlement and other businesses. We will focus on the verification of illegal acts such as over-treatment of medical institutions, fictitious medical services, illegal cashing of retail pharmacies, swapping non-medical supplies, and fictitious labor relations of insured persons.
Sixth, strengthen organization and implementation
(sixteen) the implementation of territorial responsibility.. People’s governments of counties (cities, districts) at all levels should strengthen the organization and leadership of medical insurance fund supervision, enrich the fund supervision power, and implement the responsibility of safety leadership, security, management and supervision of medical insurance fund. It is necessary to establish and improve the supervision and management system of medical insurance funds, and establish a work task ledger every year to ensure that all work is implemented. The relevant departments of the province should strengthen supervision and establish a sound accountability system. For cities where dereliction of duty and poor supervision have led to many illegal cases of fraudulent insurance or major cases of fraudulent insurance, the leaders of the provincial government or the responsible comrades of the higher authorities will interview the main responsible comrades of the governments or departments of the relevant cities and inform the province of the relevant situation. The safety supervision of medical insurance fund should be an important part of deepening the examination of medical reform.
(seventeen) to carry out publicity and education.Strengthen the publicity of medical insurance fund safety, focus on the publicity of typical cases, medical insurance laws and policies, and social insurance handling services, guide all relevant institutions and individuals to take a warning, take the initiative to participate in fund supervision, and create a good atmosphere for the whole society to pay attention to, care for and support the safety of medical insurance funds.
This opinion will be implemented as of May 1, 2018 and is valid for 5 years.
Guangdong provincial department of human resources and social security Guangdong Provincial Public Security Department
Guangdong Provincial Finance Department Guangdong Provincial Health and Family Planning Commission
Guangdong Food and Drug Administration
March 16, 2018
Attachment:Opinions on further strengthening the safety supervision of basic medical insurance funds (Guangdong People’s Social Regulation [2018] No.1)