Hubei Province, the new rural cooperative medical care designated medical institutions management measures
Generation 2008-11-0416:34:56 Source: Keywords: Hubei medical insurance
Chapter I General Provisions
Article 1 in order to strengthen the management of the new rural cooperative medical care designated medical institutions (hereinafter referred to as the designated medical institutions), standardize the behavior of health care services, control the unreasonable growth of medical costs, provide relatively high quality medical and health services for the participating farmers with relatively low costs, and promote the sustainable development of the new rural cooperative medical system. Control the unreasonable growth of medical costs, with relatively low cost, to provide relatively high quality medical and health services for participating farmers, and promote the sustainable development of the new rural cooperative medical system, according to the "Regulations on the Management of Medical Institutions" and "General Office of the Ministry of Health on the strengthening of the new rural cooperative medical institutions designated medical cost management of a number of opinions" (Health Office of the Agricultural Health Development [2005] No. 243) spirit. Combined with the actual situation in our province, the formulation of this approach.
Article II of this approach applies to the designated medical institutions at all levels in Hubei Province.
Article 3 of the new rural cooperative medical care designated medical institutions (hereinafter referred to as "designated medical institutions"), refers to the new rural cooperative medical care management agency signed a service agreement with the new rural cooperative medical care management agency, to fulfill the responsibility of the participating farmers to provide high-quality and inexpensive medical care, to comply with the relevant provisions of the new rural cooperative medical care, and to accept the management and management agencies, participating farmers and society as a whole to monitor the legitimate medical care institutions, and to ensure that the new rural cooperative medical care is provided in a timely manner. The designated medical institutions are categorized into provincial, municipal and municipal medical institutions. The designated medical institutions are divided into five levels: provincial, municipal (state), county (city, district), township (town) and village.
Article 4: The administrative departments of health at the county level and above are responsible for the approval, management and supervision of designated medical institutions in accordance with the Regulations on the Administration of Medical Institutions and the provisions of these Measures. Health administrative departments at all levels, the new rural cooperative medical management agency is responsible for the designated medical institutions of the relevant business management, inspection and guidance.
Chapter 2, the identification of designated medical institutions
Article 5 of the review of designated medical institutions should be consistent with the following principles:
(a) the principle of convenient access to medical care. The designated medical institutions shall have a reasonable layout and be convenient for farmers to seek medical treatment.
(2) the principle of reasonable structure. The main body of the designated medical institutions should be township health centers and county-level health care institutions, and a certain number of cities (states) and above, the third-level medical institutions and some specialized hospitals; Chinese medicine hospitals, hospitals combining traditional Chinese and Western medicine and ethnic hospitals should be recognized as designated medical institutions.
(C) the principle of dynamic management. The medical service behavior, quality and cost control of the designated medical institutions to carry out regular assessment and evaluation, and the results of the assessment and evaluation as the basis for re-determination of its designated qualifications.
(4) No fees shall be charged for the review, identification and assessment of designated medical institutions.
Article 6 of the review and determination of designated medical institutions and the daily supervision of the implementation of graded.
Provincial health administrative departments to apply for designated provincial and ministerial health care institutions to implement the review and determination and daily supervision. The qualification of designated medical institutions recognized by the provincial health administrative departments is valid within the province.
Municipal (state) health administrative departments of the jurisdiction of the city (state) directly under the application for designated health care institutions to implement the examination and recognition and day-to-day supervision. The qualifications of the designated healthcare institutions recognized by the municipal (state) health administrative departments are valid within the scope of the municipality (state).
County (city, district) level health administrative departments within the jurisdiction of the application for designated county-level health care institutions, township health centers, village health centers to implement the review and identification and daily supervision. The qualifications of the designated healthcare institutions recognized by the county-level health administrative departments are valid within the county (city and district).
The health administrative departments of each county (city and district) may, according to the actual situation of the local area, independently select some of the provincial and ministerial designated medical institutions recognized at the provincial level and the designated medical institutions at the municipal (state) level to be the designated medical institutions for referral in their own counties (cities and districts).
Article VII of the application for designated medical institutions should meet the following basic conditions:
(a) obtain the "Medical Practice License" and the relevant professional diagnosis and treatment of technical services access permits, professional and technical personnel with the appropriate licensing documents.
(B) the implementation of unified operation, unified fees, unified accounting, unified management.
(3) in line with the same level of "basic standards for medical institutions" requirements, and provincial and municipal designated medical institutions, general hospital beds should not be less than 300 beds, specialized hospitals should not be less than 100 beds; county (city, district) designated medical institutions scale access standards, by the county (city, district) the management of the new rural cooperative medical care to determine their own.
(4) Compliance with national laws, regulations and standards relating to medical services, medical services, sound rules and regulations, standardized management.
(v) Strictly implement the national and provincial policies on medical services and drug prices, formulate measures to control medical costs, specialize and conduct regular inspections, and strengthen self-restraint and management.
(vi) Commitment to the strict implementation of the relevant policies, systems and regulations of the new rural cooperative medical care, and the establishment of an internal management system appropriate to it.
(vii) Possesses the information management system required to undertake the designated medical services.
Article VIII Approval Procedures for Definitive Medical Institutions
(1) Medical institutions voluntarily submit applications;
(2) The management of the new rural cooperative medical care department organizes experts to carry out evaluation;
(3) Medical institutions that have passed the evaluation shall be approved by the management of the new rural cooperative medical care department.
(4) The new rural cooperative medical care administration department signs a letter of agreement with the designated medical institution and issues a certificate of qualification and a plaque to the designated medical institution.
(v) The list of designated medical institutions is announced to the public through the media to make it convenient for participating farmers to seek medical treatment, and is widely subject to social supervision.
Article IX of the medical institutions with the conditions stipulated in Article 7 of these measures, may submit a written application to the health administrative department at the same level, and submit the following materials:
(1) "Medical Institutions Practice License" (a copy of the copy);
(2) the application for the new rural cooperative medical designated medical institutions;
(3) the main business departments and diagnostic and treatment (iv) List of large medical instruments and equipment (more than 10,000 yuan at village level, more than 100,000 yuan at county level, more than 200,000 yuan at municipal level, and more than 300,000 yuan at provincial level);
(v) Hospital statistics and financial statements of hospitals in the past two years, including medical income and outpatient and inpatient consultation services, total income from medical services, the ratio of medicine income to medical income; the number of outpatient consultations, the ratio of medicine income to medical income; the number of outpatient consultations, the ratio of medicine income to medical income; and the number of outpatient consultations. The proportion of business income; outpatient visits, average cost; hospitalization visits, average cost, average hospitalization days; the implementation of single-disease management and cost control.
(F) other materials prescribed by the health administrative departments at or above the county level.
Article 10 of the health administrative department from the date of acceptance of the application within 20 working days, shall organize and complete the review of information and on-site assessment. After review and assessment of the basic conditions of the designated medical institutions, the administrative department of health issued a letter of recognition.
Article 11 of the designated medical institution is valid for two years.
Specialized medical institutions should be valid three months before the expiration of the application for renewal. Late application for continuation or review and assessment of the basic conditions of the designated medical institutions do not meet, by the original determination of the health administrative department to cancel its designated medical institution qualification and shall be announced.
Chapter III of the management of designated medical institutions
Article XII of the designated medical institutions should be clear that a major responsible person in charge of the new rural cooperative medical care related management and coordination, and set up the new rural cooperative medical care management department, with full-time (part-time) management personnel, with the new rural cooperative medical care management department*** with the management of the designated medical institutions to do a good job. Its main responsibilities are: based on the new rural cooperative medical care policy, the implementation of the unit departments to manage and supervise; is responsible for the identification and management of participating farmers patients, in accordance with the relevant provisions of the coordination of services, policy advice, hospital expenses review and reimbursement work; to do a good job of the new rural cooperative medical care medical information management, timely and accurate to the level of the new rural cooperative medical care management department to provide participants with the information of the new rural cooperative medical care management department. The cooperative medical care management department at this level shall provide the participating farmers with relevant information on medical treatment and expenses incurred.
Article 13 of the designated medical institutions shall strictly implement the Ministry of Health and the provincial health administrative departments to develop technical standards, operating procedures to ensure medical safety.
Article XIV of the designated medical institutions to strengthen the medical ethics of medical personnel, correctly deal with the relationship between social and economic benefits, and constantly improve the level of medical technology and quality of service, for the participating farmers to provide quality and reasonable price of health care services, and through good service, to promote the healthy development of health care institutions themselves.
Article 15 of the designated medical institutions shall hang the signboard of the designated medical institutions of the new rural cooperative medical care in a conspicuous position of the institution, set up the "new rural cooperative medical care complaint box", and publicize the basic policies of the new rural cooperative medical care and the basic drug list, the basic diagnostic and therapeutic items, and the prices of the commonly used medicines at the appropriate positions of the outpatient clinics and wards. The prices of commonly used medicines are also publicized at appropriate locations in outpatient clinics and wards.
Article 16 of the designated medical institutions shall provide relevant training for their staff to enable them to master the basic policies, practices and requirements of the new rural cooperative medical care, and to be able to publicize, explain and interpret the relevant policies to participating farmers and their families.
Article 17 of the fixed-point medical institutions shall strictly enforce the standards of entry and exit of hospitals, the implementation of the two-way referral system; should be based on the treatment of disease, reasonable use of medicines, reasonable inspection, reasonable fees, and correctly guide the participating patients to seek medical treatment, to control the irrational growth of medical costs. It is prohibited to link income from medical expenses to the personal income of medical personnel.
Article 18 shall give full play to the characteristics and role of traditional Chinese medicine in rural medical and health services, and advocate the use of traditional Chinese medicine, and promote the use of appropriate technology of traditional Chinese medicine.
Article 19 of the designated medical institutions to standardize the channels of importing drugs, reduce the inflated prices of drugs. The rate of drug markup and the retail price of drugs shall not be higher than the standard set by the local price department.
Article 20 Outpatient Management
(1) When a participating farmer patient seeks medical treatment, the medical personnel of the designated medical institution must check the "New Rural Cooperative Medical Care Certificate" of the patient, so as to make sure that the person and the certificate are in line with each other, and to eliminate impersonation. Medical personnel have the right to retain the impersonation of the new rural cooperative medical card, and submitted to the designated medical institutions of the new rural cooperative management department, to the county (city, district) new rural cooperative medical management department in accordance with the relevant provisions of the treatment.
(2) The outpatient prescriptions of the designated medical institutions for enrolled patients shall be differentiated from those of non-participating patients.
(3) When a participating farmer patient visits a clinic, outpatient prescription medication is managed in a quantitative manner. A single outpatient prescription dosage shall not exceed three days for emergency patients and seven days for general patients, and the same type of drugs shall not be repeatedly prescribed.
Article 21 Hospitalization Management
(1) The designated medical institutions shall strictly control the indications and standards for admission, treatment, surgery and discharge, and shall not accept patients who do not meet the hospitalization standards for enrolment, nor shall they refuse to admit patients who meet the hospitalization standards for enrolment.
(2) After a participating farmer patient is admitted to the hospital, the cooperative medical management department of the designated medical institution shall verify the identity of the participant, follow up and check the hospitalization and treatment, and put an end to such irregularities as impostor and hospitalization in a registered bed.
(3) The hospitalized medical records of patients enrolled in the designated medical institutions shall be marked with the logo of "enrolled patients" in an appropriate place.
(4) The designated medical institutions and their medical staff shall strictly implement the "Hubei Provincial New Rural Cooperative Medical System Basic Medicines Catalog (Second Edition)", "Hubei Provincial New Rural Cooperative Medical List of Proprietary Chinese Medicines, Drinking Tablets and Herbs" (hereinafter referred to as the "Medicines Catalog"), and the guiding principles for the use of antibiotics, and other relevant regulations, and shall carry out the use of medicines in a graded manner, and make reasonable medication dispensing, and shall not misuse medicines, prescribe large prescriptions, or prescribe humane prescriptions. The company has been working on a number of projects, including the development of a new product line, the development of a new product line, the development of a new product line, the development of a new product line, and a new product line.
The clinical use of medicines for participating patients should be prioritized within the scope of the drug catalog, and self-financed medicines that are beyond the basic drug catalog due to the needs of the patient's condition should be notified to the patient or his/her family members and agreed upon with his/her signature, and at the same time, the words "at his/her own expense" should be indicated on the prescription. The designated medical institutions at all levels should control the cost of drugs outside the catalog as a proportion of the total cost of drugs, the provincial and ministerial-level designated medical institutions to control within 25%, city (state) level designated medical institutions to control within 20%, county (city, district) level designated medical institutions to control within 15%, township (township) level designated medical institutions to control within 5%.
(5) Hospitalization prescriptions are in accordance with the relevant provisions of the "Prescription Management Measures" issued by the Ministry of Health, and all prescription drugs use the chemical or common names of the drugs (which can be labeled with the trade names), and may not use the trade names alone.
(6) The designated medical institutions and their medical staff shall strictly grasp the indications of large-scale equipment inspection, and shall not use special inspection to confirm the diagnosis with routine inspection, and shall not use special inspection which has nothing to do with diagnosis and treatment. If the condition of the patient requires self-funded or partially reimbursed large-scale instrument and equipment examination, the patient or his/her family should be informed of this, and his/her signature should be obtained. Higher hospitals have been examined and issued a report on the results of the examination, the lower hospitals should be recognized, the hospitals at the same level issued a report on the results of the examination should be mutually recognized, shall not be duplicated.
(7) The designated medical institutions shall adopt appropriate means to implement the one-day list system of expenses, so as to facilitate the enrolled patients' inquiries and the audit of the new rural cooperative medical care management institutions. When a participating patient is discharged from the hospital, the designated medical institution shall issue a detailed list of hospitalized medical expenses. Costs incurred for drugs, examinations, treatments and other items not paid for by the New Rural Cooperative Medical Care Fund shall be listed separately on the hospital discharge settlement list. The designated medical institutions should also actively implement the data docking work between the fee management system of the designated medical institutions and the information management system of the new rural cooperative medical care.
(H) The designated medical institutions shall not convert the diagnostic and treatment items for which the new rural cooperative medical care is not allowed to pay fees into reimbursable items, let alone allow them to be broken down into other items.
(ix) the designated medical institutions to participate in the patient's hospital discharge with drugs should be implemented prescription regulations, strict control of the amount of drugs discharged from the hospital, general acute diseases hospital discharge with drugs shall not exceed 7 days of dosage, chronic diseases shall not exceed 15 days of dosage.
(j) Participating farmers in the specialty designated medical institutions, in principle, is limited to the main treatment of the specialty disease and its complications. Diagnosed as non-specialty diseases, to inform the participating farmers patients, such as the participating farmers patients do not agree to continue treatment in the hospital, should be promptly discharged or transfer procedures.
(xi) Medical expenses incurred in violation of the above provisions shall be borne by their designated medical institutions.
Article 22 of the fixed-point medical institutions shall incorporate the implementation of the new rural cooperative medical system into the content of the assessment of departments and staff, and conduct regular assessment and evaluation, and linked to the target management assessment and bonus allocation.
Article 23 cost settlement management
(1) The designated medical institutions and their staff shall strictly abide by the relevant provisions of the management of the writing of medical documents, non-personal diagnosis and examination, shall not issue medical documents, and shall not issue their own scope of practice has nothing to do with the medical documents or not in line with the type of practice, is strictly prohibited to issue false certificates, false medical records, false prescriptions, false bills. It is strictly forbidden for any unit or individual to take advantage of their work to obtain funds for cooperative medical care by fabricating false medical records, issuing false bills or any other means.
(2) the designated medical institutions should be arranged to specialize in or determine the relevant personnel responsible for handling the audit and settlement of medical expenses of participating patients. Counties (cities, districts) at all levels of fixed-point medical institutions in the settlement of medical expenses for participating farmers, in accordance with the relevant provisions of the new rural cooperative medical care in a timely manner to advance the subsidy funds, and is strictly prohibited to raise or lower the standard of compensation without authorization. The subsidized funds advanced by the designated medical institutions for the participating farmers are regularly summarized and reported to the cooperative medical institutions, and are approved and allocated according to the regulations.
Article 24 of the county (cities, districts) new rural cooperative medical management should be set up with the designated medical institutions to establish a work coordination mechanism, regular or occasional verification of participating farmers discharged from the hospital patients' medical expenses and other circumstances, the designated medical institutions should be actively cooperate.
Chapter IV Supervision of Defined-Point Medical Institutions
Article 25: In the performance of their duties, the new rural cooperative medical care administration and its personnel shall have the right to exercise the following powers:
(1) to ask the person in charge of the defined-point medical care institution and the person concerned about the medical services and settlement of expenses related to the new rural cooperative medical care;
(2) to access and inquire about the medical records (case files) of patients participating in the cooperative medical care;
(2) to inquire about the medical expenses of patients participating in the cooperative medical care. (ii) access to and inquire into the medical records (cases), prescriptions, medical instructions, fee lists and fee bills of the participating patients;
(iii) if necessary, temporarily sealing the relevant information of the participating patients with the designated medical institutions. The fixed-point medical institutions shall cooperate and take the initiative to provide relevant information.
Article 26 of the fixed-point medical institutions shall, in accordance with the provisions of the administrative departments of health and the new rural cooperative medical management institutions at all levels, regularly report relevant information and statistical reports. The new rural cooperative medical care management institutions shall establish a system for monitoring and releasing information on the services of designated medical institutions, timely collection, summary, synthesis and analysis of the medical expenses of patients enrolled in designated medical institutions within the jurisdiction, and regularly publish monitoring information.
Article 27 The new rural cooperative medical care management organization shall carry out on-site verification when it encounters the following cases:
(1) when it receives complaints about the random examination and abuse of drugs by the designated medical institutions, which increase the burden of patients;
(2) when it reviews the medical expenses of the participating patients, it finds that the proportion of the reimbursable medical expenses is obviously lower than the average level of the designated medical institutions at the same level;
(3) when it finds that the proportion of the reimbursable medical expenses is significantly lower than the average level of the designated medical institutions at the same level. /p>
(3) found suspected of impostor, fraud, arbitrage new rural cooperative medical funds;
(4) other necessary to carry out on-site verification.
Article 28 of the health administrative department shall carry out a comprehensive assessment of the designated medical institutions every year to assess the problems and formulate corrective measures to ensure the smooth implementation of the new rural cooperative medical care system. For the assessment of the assessment failed designated medical institutions medical, shall suspend its designated qualifications.
Chapter V violations
Article 29 of the relevant provisions of the violation of these measures, by the health administrative department to be admonished in writing, and urged to correct the seriousness of the situation to be notified; three consecutive admonition is still not correct, depending on the circumstances of the cancellation of the qualification of designated medical institutions.
Article 30 of the fixed-point medical institutions and their staff without authorization to raise the standard of compensation, the new rural cooperative medical care management organization shall refuse to settle the increased standard part of the costs borne by the fixed-point medical institutions; the fixed-point medical institutions and their staff without authorization to lower the standard of compensation, the administrative department of health ordered to return the costs to the participating patients; fixed-point medical institutions and their staff In the event that they violate the regulations and increase the burden on the participating patients, the new rural cooperative medical care management organization shall deduct the part of the illegal expenses from the compensation.
Article 31 If a designated medical institution and its staff falsify, fabricate false medical records, or issue false bills to obtain funds for the new rural cooperative medical care, the health administrative department at the county level or above shall order the institution to return the funds it has obtained; if the circumstances are bad enough, it shall be disqualified as a designated medical institution and the person directly responsible shall be subject to administrative penalties.
Chapter VI Supplementary Provisions
Article 32 of these measures shall come into force on January 1, 2008 onwards.
Article 33 of these measures shall be interpreted by the Department of Health of Hubei Province.
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