What should the hospital do a good job of supervision of the medical insurance fund?

The medical security fund is the "life -saving money" of the people. Maintaining the safety of medical insurance funds is an inevitable requirement for practicing the people -centered development thinking. It is the common responsibility of the whole society. The use of medical insurance funds mainly occurs in the large -scale and wide range of medical treatment. This feature determines that designated medical institutions that provide medical services have more important responsibilities in maintaining the safe use of the fund. This article combines the practice of Peking University People's Hospital to talk about the study and implementation of the "Regulations on the Supervision and Administration of the Medical Security Fund" to strengthen the main practices, results and thinking of the use of supervision and management in the medical insurance fund hospital.

Strengthen the construction of the hospital system, regulate medical service behavior in accordance with the law

The use of institutions to manage people is a policy of strengthening the use of supervision and management of medical insurance funds, and it has formed a normalization approach. The concept of strengthening the system construction of Peking University is closely linked to the construction process of the rule of law of the country and Beijing's medical insurance, closely contacted the actual situation of medical services in our hospital, and advanced with the times to strengthen the construction of the medical insurance fund use of the hospital's internal supervision system. On December 9, 2021, the "Implementation Measures for the Supervision and Management of the Medical Insurance Fund of Peking University People's Hospital" (hereinafter referred to as the "Implementation Measures"). This is the "Regulations on the Supervision and Administration of the Medical Security Fund" (hereinafter referred to as the "Regulations") in accordance with the "Medical Security Fund" (hereinafter referred to as the "Regulations" promulgated by the State Council), and the "Beijing Medical Insurance Improvement Measures and the Administration of Budgets" 〕 No. 26) The formulation of relevant laws and regulations, rules and regulations, and standardized documents such as the "Beijing Basic Medical Insurance Designated Medical Institutional Agreement" and other relevant laws, regulations, and regulatory documents, which reflect the same resonance as the construction of the rule of law in the rule of law. The "Implementation Measures" formulated by the People's Hospital of Peking University has the following characteristics.

The hospital vote for the publicity of the fund supervision and publicity content in the outpatient hall, which aims to expand the scope of publicity and create a good atmosphere of the safety of medical insurance funds to maintain the safety of the medical insurance fund.

First, the purpose and basic principles of the system are consistent with the "Regulations". The institutional construction idea of ​​our hospital is that the "Regulations" are national administrative regulations. They are in charge of the country. As a national three public hospitals, they should consciously take the lead in implementing national regulations. It is reflected in the construction of the institutional system, and it should be consistent with the national "Regulations" on major issues such as the purpose of the system and the principles of the system. Based on this idea, the hospital's "Implementation Measures" explicitly proposed to improve the efficiency of medical insurance funds in hospitals, strengthen supervision and management of the use of medical insurance funds in the hospital, and ensure that the interests of insured personnel and hospitals are not suffered from losses. The basic principles are based on regulating medical service behaviors, standardizing the professional behavior of physicians, promoting the construction of healthy China, and guiding the use of medical security funds in accordance with the law.

The second is to contact the actual formulation of specific terms to reflect the extension of the national legal system. The comprehensive implementation of the "Regulations" needs to conduct responsibility, motivation, and pressure on layers, and has been transmitted to all parties in interest. Among them, designated medical institutions are the most important. Because designated medical institutions are responsible for heavy and complex medical service tasks, it is not only the largest subject used by medical insurance funds, but also the main breeding place for the risk of fund losses. Therefore, the responsibility, power and pressure of the "Regulations" will be implemented to designated medical institutions to make it a behavioral specification for medical institutions and medical personnel to provide medical services, and the promulgation and implementation of the Regulations will be practical. To this end, the provisions of the relevant medical institutions and medical staff stipulated in the "Regulations" in the "Regulations", in accordance with the attitude of responsibility to the people and the implementation of national law, have made strict refinement in the "Implementation Measures" one by one The regulations are strictly restrained the medical service behavior of medical staff and strictly prohibit violation of violations of the "Regulations". For violations of laws and regulations, once found, punishment will be strictly obtained. For example, Article 28 of the "Implementation Measures" stipulates that the medical insurance credit management system is established. If individual medical personnel have repeatedly occurred, the main responsibility department will submit the medical insurance fund supervision and management leading group and the working group to make decisions. Depending on the severity of the circumstances, its prescription rights are suspended, and the functional departments are rotated to study. Because the "Implementation Measures" in the hospital are strict and in line with the reality of the hospital, they are very targeted and operable, and the consciousness of implementing the "Implementation Measures" is unprecedentedly improved. From the implementation of the "Regulations" from May 1, 2021 to the end of April 2022, the hospital has initially formed a good atmosphere of the "Regulations" and "Implementation Measures" together. This shows that the "Implementation Measures" has played the role of the "Regulations" to the bridge and bond of medical behavior of hospitals and medical staff, enhance the ownership responsibility of implementing the "Regulations", and reflect the social value of the "Implementation Measures".

The third is to carry out various forms of mission training and build a good atmosphere to implement the "Regulations". After the "Regulations" was promulgated, the hospital not only formulated and introduced the "Implementation Measures" in a timely manner, but also carried out training activities for learning and publicity and implementation of the "Regulations" and "Implementation Measures". Use the good atmosphere of the Regulations to make the implementation of the "Implementation Measures" a conscious behavior of all medical staff. Training adopts online and offline combination, collective training with individual self -research, combination of practice and control system terms, hospital leaders and medical insurance office staff to promote the difficult problems raised by the daily answer to the medical department Wait. Multiple ways of mission and training have normalized the propaganda and learning activities of the Regulations and Implementation Measures, and promoted the in -depth integration of the "Regulations" and "Implementation Measures" and medical services. Effect. Carry out full -time supervision and inspection, standardize medical service behavior in practice

As a large -scale public triple comprehensive hospital, the number of outpatients of Peking University People's Hospital has a large number of outpatient emergency consultations. In 2021, the number of emergency visits in 2021 reached 2.78 million. In addition, the patient's condition was complicated. Essence However, the People's Hospital of Peking University has always strictly implemented the Regulations and the "Implementation Measures" matched with the "Regulations". By carrying out the full supervision and inspection of advance, events, and afterwards, the quality of medical services and reasonable use of medical insurance funds are ensured.

Make enough supervision beforehand

The hospital's medical insurance office implements standardized, institutionalized and refined medical insurance fund supervision and management. The staff of the entire department regularly organize the study of the "Regulations", "Implementation Measures", and new medical insurance policies and requirements. Through collective learning and discussing doubts, form consensus, boost morale, innovate methods, and continue to do a good job of training in medical insurance policy in the hospital and outside the hospital (such as insured) medical insurance policy and cracking down on fraudulent insurance publicity work.

The first is to establish a medical insurance management officer online and offline dual -track and parallel linkage mechanism. Through Internet channels such as WeChat Group, Tencent Conference, Hospital HRP Website, etc., the latest medical insurance policies are conveyed, and the problems found in daily supervision work will continue to emphasize the importance of real -name medical treatment and prescribing medicine registration and its legal significance Essence The regular medical insurance work conference is held offline to report the latest illegal fraudulent insurance issues and some fraudulent insurance cases discovered by the medical insurance departments at all levels at all levels, and collect the opinions and suggestions of the clinical departments at the meeting. After the meeting, the Medical Insurance Office also sent the important content of the meeting and the various medical insurance assessment data of the department to send a specialized manager's mailbox, and copied it to the person in charge of the department.

The hospital conducts various publicity and implementation of the "Regulations on the Supervision and Administration of the Medical Security Fund" around publicity and implementation, and actively publicize relevant publicity through posting posters, broadcasting publicity, and issuing manuals in the clinic area.

The second is to carry out the propaganda work of all employees to crack down on fraud. Relying on the Internet platform, all personnel such as patients and medical technology care are implemented. Through the large -screen screen and the TV screens of the outpatient building, the publicity data of cracking down on fraudulent insurance will be played non -stop during working hours, allowing patients to watch at any time. Poster the poster of the publicity of fraudulent insurance in key areas with a large area of ​​patients, and also put the crackdown of fraudulent budding manuals on the waiting area of ​​patients on all floors on the outpatient hall, the nurse stations, the outpatient office, and the inpatient department to handle business windows and other obvious locations. , Expand the propaganda surface. The Medical Insurance Office also reposted the policies and regulations of various medical insurance funds in the WeChat group, analyzing cases, and punishment measures of various medical insurance funds, and continuously enhanced the awareness of the internal staff of the hospital for fraudulent insurance hazards, enhanced awareness of prevention, promoted to promote The whole hospital resisted the fraudulent behavior together. At the same time, it evokes the patient's sense of responsibility to maintain his "life -saving money".

The third is to collect medical insurance issues encountered in the clinic and make knowledge bases. In order to facilitate clinical doctors in different posts, doctors can better be familiar with medical insurance policies and regulations, especially the terms of the Regulations and Implementation Measures. Book, convenient to read in time with you. The conventional version is distributed for each clinical department, so that the doctors in the ward can first consult the confusion after encountering problems and deal with the problems that occur in time. The two prongs can not only make senior physicians clarify medical insurance -related policies, but also allow newly -admitted doctors to understand medical insurance policies and regulations as soon as possible. They can reach the same in the hospital in a short period of time to avoid the occurrence of fraud insurance incidents.

Supervision in a strong matter

In order to cooperate with the special operations of combat fraud and fraud and fraudulent medical insurance funds, the People's Hospital of Peking University was issued by the leadership team of the hospital and the main leaders of the medical insurance payment standard management leading group and working group of the leaders of the hospital of Peking University. At the same time as the "Implementation Measures", the "Administrative Measures for Medical Insurance of the People's Hospital of Peking University" was also introduced. At the same time, the hospital also organized the establishment of the National Basic Medical Insurance Fund Audit to find out the rectification and self -examination and self -correction leadership group and working group. The team members revised the relevant systems and processes in a timely manner for the problems found in the inspection, and notified the relevant departments to conduct carefully rectification.

The staff of the hospital's medical insurance office regularly organizes the latest policies for supervision of the medical insurance fund, in -depth research on some announced fraud cases, and promotes the atmosphere of the rule of law of the law, learning, law -abiding, and usage. The first is the joint operation of multi -disciplinary rooms to defend zero tolerance for fraud. 11 departments including medical insurance, medical insurance, finance, operation, operation, pharmacy, defense and disciplinary inspection rooms, organize training in the hospital, optimize the existing medical insurance interception system of the outpatient doctor workstation, monitor key abnormal data, analyze the outpatient prescription prescriptions Comment and improve internal control in the review of discharge cases. It was found that unreasonable charging items, super -medical insurance limited medications, etc., contacted and verified the situation with the corresponding department at the first time, and proposed rectification suggestions. Comprehensively monitor the key data of the outpatient clinics and real -name reports, and use big data comparison, prescription reviews, face -to -face interviews, etc. to analyze the prescriptions of illegal regulations. Prompt the system control, verify that the insured returns the medical insurance fund involved, and eliminate the waste of the fund. The insured persons who have repeatedly taught and not changed to the market and district medical insurance supervision and inspection departments, and use the hospital's "blacklist" interception system to intercept from the hospital. Essence

The second is to introduce third -party software platforms to promote intelligent review. In order to continuously strengthen the intra -hospital supervision work used by the medical insurance fund, the medical insurance office introduced a third -party software platform to use information technology to docking the doctor's workstation in the hospital. Through the rules engine configuration, the relevant clinical medical rules, charging rules, and medical insurance policy rules are integrated into system. The management department can also add personalized review rules according to the actual situation of the hospital at any time, so that the system can more accurately and efficiently review illegal prescriptions or information information, and standardize doctors' diagnosis and treatment services. At the same time, the automatic analysis and monitoring function of medical treatment information and hospital settlement information data is realized, and the transformation of medical insurance costs to supervision to the supervision of the post -after -to -the -after and during the event will better ensure the security of the fund.

The third is to refine high -value medical consumables to achieve the whole process. Establish a leadership group and medical consumables management team of hospital medical consumables management committees, and clarify their work responsibilities. Formulate institutional documents such as the "Administrative Measures for Medical Consumption (Trial) of Peking University People's Hospital (Trial)" and "Administrative Measures for the Procurement of Medical Consumption (Trial) of the People's Hospital of Peking University". Clinical use of safety control and risk management for full process regulations. Orthopedic use of non -implanted disposable high -value consumables is managed by physical acceptance and one code for one size. The department scan the code fee, automatically connects HIS in the courtyard, and realizes the full traceability of the manufacturer-logistics-use-patients. Through this model, the hospital realizes cost reduction and efficiency, avoid fraudulent insurance such as external consumables, low -cost consumables, high fees, and repeated charges of disposable consumables to improve the precision level of medical insurance fund supervision.

After the postponement supervision

The first is to use informationization methods to establish a "blacklist" interception system in the courtyard. In the illegal insured person with illegal insured, key monitoring objects (work injury identity and retired identity), and abnormal dynamic monitoring data in the hospital for full -time system monitoring. When the outpatient doctor workstation detected the above three types of insureds during the outpatient clinic, the workstation would pop up the intercepting prompts to remind the doctor to strengthen the prevention. After seeing the prompt, the doctor could stop the monitor to continue the medical treatment and inform him of the hospital's medical insurance office for verification. After verifying the unlocked unlocked, the consultation is continued. For example, during the supervision of the daily fund, multiple batches of patients injured patients were prescribed in a large number of medicines in different departments. The medical insurance office provided suspicious data provided by the clinical department in a timely manner. "Blacklist" interception system focuses on monitoring. After taking regulatory measures, after data comparison, the number of people suspected of working injuries dropped by 60%, and the fund payment amount decreased by 83%(see Figure 1). It can be seen that comprehensive supervision can efficiently lock the target. Using the information interception system can greatly improve the efficiency of supervision, control the spread of violations in a short period of time, and strictly beat the scammers.

The second is to combine clinical problems and make rectifications. In order to maintain a fair and orderly medical environment, to severely crack down on fraudulent violations, and for the clinical department or individual doctors that violate the "red line" that violates the "red line" of medical insurance policies and regulations, if the first unintentional or light circumstance Individuals, and the training of illegal doctors conducted medical insurance regulations alone, and preached the "Regulations" and "Implementation Measures" to them. Regarding the illegal issues with conclusive evidence, the formal rectification notice will be issued on the illegal department or individual, and the person in charge of the department and the core team of the core team will be rectified. For the departments or individuals that have not been effective after many notifications, according to the severity of the circumstances, in accordance with the provisions of the Regulations and the Implementation Measures, they notified criticism at the hospital meeting, and the relevant expenses involved in the personal punishment of the physician's personal punishment of violations of regulations are The circumstances of the circumstances are more seriously reported to the supervision and inspection agency of the City Medical Insurance Bureau to avoid the use of the first "firewall" from the outpatient doctor from the clinic.

Continue to promote the construction of the rule of law, build a safety defense line of the medical insurance fund

Although the work of maintaining the safety of medical insurance funds in Peking University in accordance with the law has achieved results, this is just the beginning. The task of maintaining the safety of medical insurance funds is long -term, and it is our best choice to continue to implement the "Regulations". The next step will continue to make efforts in the following aspects. The hospital actively responded to the promotion month activities of the Beijing Municipal Medical Security Fund's "Regulations on the Supervision and Management of the use of the Medical Security Fund", and invited the leaders of the Municipal and District Medical Insurance Bureau to conduct in -hospital training on the content of the regulations.

The first is to continuously strengthen political consciousness and people's consciousness. Really understanding and understanding the medical insurance fund is the deep connotation of the people's "life line", consciously raising the work of maintaining the safety of maintaining the fund to adhere to the height of "people first, life first", and deeply realize that the maintenance of the people's interests to the people's interests of the people It is a political, ensuring the security of the fund's use of the central government, and the political requirement.

The second is to continuously strengthen the concept of common responsibility of medical and medical insurance. As a medical service provider, the concept of the reform of medical and medical insurance linkages, synergistic governance, mutual benefit and win -win, and common development should be treated. Because medical and medical insurance has a natural inner connection, the two have a common purpose and common goals, that is, they are serving the people's health, both are committed to achieving the strategic goal of healthy China. Under this common purpose and common goal, ensuring the safety of medical insurance funds should become the common responsibility of medical and medical insurance.

The third is to continuously strengthen and improve the governance mechanism according to law. The promulgation and implementation of the "Regulations" provides institutional guarantee for governance in accordance with the law. The implementation of the "Regulations" in an all -round way must have both thinking in accordance with the law and relevant supporting measures to follow up. The "Implementation Measures" formulated by the hospital provides specific paths for the hospital's implementation of the "Regulations", but the implementation of the "Implementation Measures" also needs to do a lot of hard and meticulous work, including conducting full coverage and sustainable supervision and inspection of medical diagnosis and treatment. Do not leave any space for fraud and fraud; continue to implement the "zero tolerance" blow to illegal and illegal acts, increase the cost of illegal and violations from various aspects such as practice, credit, and medical treatment. "Let the deception. In the next step, we will continue to do a good job of improving the "Implementation Measures" in the implementation of the new situation and new problems encountered in the "Regulations", and further build a safety defense line at the People's Hospital of Peking University.

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