The national medical insurance flight inspection has been started, which can cover the designated pharmacies src = "/mmbiz _ jpg/i4szibeshm07NB7xwkqcna8Z80Ryqrlhdo2FX XR5FMD7Kog39P6Psp5Kaz5Qz0fbTic6CricumyicrBDXLuua/640? wx _ fmt = JPEG "/& gt； National medical insurance flight inspection
Underwriting designated pharmacies
A few days ago, the website of the State Supervision Commission of the Central Commission for Discipline Inspection issued a document saying that the staff of the flight inspection team had been stationed in Yunnan to carry out the flight inspection of the medical insurance fund in 2022.
According to the requirements of the Notice on Carrying out Flight Inspection of Medical Insurance Fund in 2022 issued by the National Medical Insurance Bureau on May 3 1, in the second half of this year, the National Medical Insurance Bureau, the Ministry of Finance, the National Health and Wellness Commission and state administration of traditional chinese medicine will jointly organize the flight inspection of medical insurance fund, covering 3 1 provinces in China.
It is mentioned in this document that the time range of this medical insurance flight inspection will be the use of medical insurance funds since June 65438+ 10/in 2020 (that is, the use of medical insurance funds in the past two and a half years).
In addition, the medical insurance flight inspection targets are national designated medical institutions and county-level medical insurance agencies, and relevant institutions and insured persons can expand as appropriate. This means that local departments can take designated pharmacies as flight inspection targets.
According to past experience, the inspection contents of designated pharmacies are usually "three prohibitions" and "five norms"-prohibiting theft of medical insurance vouchers, taking personal accounts, providing false invoices, standardizing purchase and sale management, standardizing business items, standardizing information systems, standardizing service behavior and standardizing drug registration.
Cyber blue- The pharmacy manager found that the inspection points of designated pharmacies announced by local departments mainly include the following 14 aspects.
1. Whether it meets the requirements for the establishment of designated retail pharmacies for medical insurance, whether it carries out publicity to combat fraud and insurance fraud, and forms a publicity atmosphere in the stores.
2. Whether drugs and non-drugs, prescription drugs and over-the-counter drugs, external drugs and internal drugs are managed according to regional classification, and there are eye-catching proprietary marks.
3. Whether the pharmacist or licensed pharmacist is on duty during the business period, and whether there is any act of forging or altering prescriptions to distribute drugs.
4. Whether to sell prescription drugs illegally depends on whether the prescription drugs sold by prescription have been requested or retained.
5 whether to defraud the medical insurance fund by exchanging drugs, consumables and articles.
6. Whether to operate beyond the scope.
7. Whether to operate counterfeit and inferior drugs, and whether there are illegal drug sales on the Internet.
8. Whether to buy drugs from illegal channels and illegally recycle drugs and packaging.
9. Whether the drug purchase, receipt, acceptance and sales records are entered into the computer system, and whether the data of the computer system are true, complete and traceable.
10. Whether the cold chain transportation and storage of refrigerated drugs meet the requirements.
1 1. Whether to illegally sell prescription drugs or illegally deal in drugs containing stimulants.
12. Whether to use the national unified medical insurance code as required.
13. Whether the electronic medical insurance voucher is used normally.
14. Whether to allocate drugs for other pharmacies not in the same chain, or pay by credit card for non-designated pharmacies or other institutions, etc.
Drugstore stringing drugs to cheat insurance
The medical insurance department refused to pay 2.54 million yuan
This year, in order to reduce the phenomenon of pharmacies defrauding medical insurance funds, the National Medical Insurance Bureau announced many typical cases.
On May 28th, the National Medical Insurance Bureau issued 10 insurance fraud cases, all related to designated pharmacies. Among them, a chain pharmacy in Jilin took nearly 2.54 million yuan of medical insurance funds through drug exchange.
The local medical insurance department decided to refuse to pay the illegally used medical insurance fund and terminate the medical insurance service agreement. Chain pharmacies may not apply for medical insurance qualification within three years. In addition, a pharmacy in Zhejiang was fined twice as much as 340,000 yuan for illegally using the medical insurance fund of about 6.5438+0.7 million yuan.
Not only the national medical insurance bureau, but also the medical insurance departments in many places have exposed a number of typical cases of cracking down on pharmacy fraud.
Recently, Heilongjiang Provincial Medical Insurance Bureau reported 10 typical cases, in which a chain pharmacy defrauded the medical insurance fund by swiping cards for non-designated institutions. According to the relevant regulations, the medical insurance department recovered the medical insurance fund yuan and terminated the medical insurance service agreement of the pharmacy.
In August this year, Hubei Daily reported that the Supervision Committee of Xiaogan City Commission for Discipline Inspection, medical insurance, market supervision, public security and other departments set up a special inspection team on the issue of "three holidays" and investigated the problem of fraudulent insurance in designated medical institutions such as hospitals and pharmacies in the form of unannounced visits. Up to now, the special inspection team has handled 225 designated medical institutions, and recovered the principal of the medical insurance fund 1 10,000 yuan, liquidated damages 1 10,000 yuan, administrative penalties 1 10,000 yuan and other penalties 1 10,000 yuan.
In June this year, Yancheng Medical Insurance Bureau of Jiangsu Province exposed a number of insurance fraud cases. Among them, 1 pharmacy has irregularities that are inconsistent with the actual sales situation and the management data of invoicing. The amount of violation is RMB, and the medical insurance department will handle it as follows: 1. Recover the illegal amount of RMB; 2. Impose a fine of RMB.
For drugstore operators, in order to avoid being punished, it is very necessary to distinguish the "fraudulent insurance" behavior of pharmacies. To this end, Chongqing Medical Insurance Bureau summarized the following seven kinds of pharmacies' "fraudulent insurance" behaviors:
1. Items beyond the payment scope of the medical insurance fund shall be included in the settlement of the medical insurance fund.
2. Withdraw funds through virtual projects.
3 to provide credit card accounting services for non-designated retail pharmacies or to include the expenses incurred by non-designated retail pharmacies in the medical insurance fund settlement.
4. Changing medicines, consumables and articles for the insured to defraud the medical insurance fund.
5. Falsely issuing invoices or providing false invoices for the insured.
6 to induce the insured to buy cosmetics, daily necessities and other items outside the scope of medical insurance fund payment.
7. Acts prohibited by other laws, regulations and agreements.
Report pharmacy fraud
The highest prize is 65438+ ten thousand.
In order to better solve the problem of fraudulent insurance in designated pharmacies and medical institutions, the state encourages the introduction of social supervision forces outside government agencies.
2002165438+February, the Administrative Measures for Flight Inspection of Medical Insurance Funds (Draft for Comment) issued by the National Medical Insurance Bureau mentioned that if the complaint clues reflect that there may be major security risks in medical insurance funds, and the news media exposes them and causes significant social impact, the medical insurance department may carry out flight inspection.
The Interim Measures for Handling Reports on the Supervision and Management of the Use of Medical Security Funds, which came into effect on March 1 2022, emphasizes that medical security administrative departments at all levels should unblock reporting channels and strengthen the specialization and integration of reporting channels; Upon verification, the administrative department of medical security will reward those who meet the reporting reward conditions.
For the reward of "fraudulent insurance", it is clear that the highest reward for informants is 65438+ 10,000 yuan.
For example, the Xinjiang Medical Insurance Bureau recently issued an announcement to encourage the masses to actively supervise and report the phenomenon of "fraudulently using the insurance information of dead people to defraud insurance". If the report is true, the whistleblower can get a reward of up to 654.38+10,000 yuan.
In August this year, Sichuan Ziyang Medical Insurance Bureau and Finance Bureau jointly issued a document, welcoming the broad masses of people to report fraudulent insurance. After investigation, the qualified informants will be rewarded, and the maximum reward amount for each case is 6,543,800 yuan.