The inspection items are multi-faceted.
According to statistics, since 2019, the National Medical Security Administration has organized 130 unannounced inspection teams to inspect 268 designated medical institutions, 56 medical insurance agencies, and 40 commercial insurance companies. The amount of suspected violations of laws and regulations was found to be 2.772 billion yuan, accounting for 8% of the total funds recovered in the past two years. Based on the practice of participating in unannounced inspections, the author believes that to carry out unannounced inspections of medical insurance fund supervision under the new situation, it is necessary to firmly establish systematic thinking, strictly abide by the bottom line of regulations, improve professional standards, and strive to write four articles of "seeing, welcoming, checking, and optimizing" , to further promote the quality and efficiency of unannounced inspections and make them more in-depth and practical.
1. View it correctly
Unannounced inspection is a unilateral, profit-and-loss administrative act. Although administrative decisions are not directly made during the inspection process, the basic principles of administrative rule of law must still be followed. In particular, inspection subjects and inspected objects should have a correct understanding of the essentials of unannounced inspections, proactively adapt to the trend of unannounced inspections, and work together to create a good environment conducive to the in-depth advancement of unannounced inspections.
From the origin, unannounced testing was first used to detect doping in sports competitions. In 2006, my country took the lead in establishing an unannounced inspection system in the field of drug supervision, and gradually formed a relatively complete set of unannounced inspection work processes, which played an important role in investigating problems, managing and controlling risks, and deterring illegal activities. Since the establishment of the National Medical Security Administration, it has organized unannounced inspections in the field of medical insurance fund supervision. By establishing unannounced inspection procedures, making overall arrangements, and guiding provinces, autonomous regions and municipalities to coordinate their advancement, the comprehensive effect of unannounced inspections has been greatly enhanced.
From a definition point of view, the unannounced inspection of medical insurance fund supervision is the medical security department’s inspection of designated medical institutions, medical insurance agencies and their staff, commercial insurance undertaking agencies and their staff, insured persons, etc. within their jurisdiction. Conduct unannounced supervisory inspections involving the use of medical security funds. It can be seen that the subject and object of the unannounced inspection are clear, and not informing in advance is the key. Suddenness, confidentiality, and shock are its main characteristics.
From the basis, it covers substantive and procedural norms. The national level includes the Social Insurance Law, the Regulations on the Supervision and Management of the Use of Medical Security Funds, the Medical Security Fund Supervision Unannounced Inspection Procedures, and the comprehensive implementation of the administrative law enforcement publicity system for the medical security system. The entire law enforcement process recording system, the implementation methods of the legal review system for major law enforcement decisions (trial), the notice on the follow-up work of standardizing medical security fund supervision unannounced inspections, etc.; the local level includes local medical service project prices, medical insurance cost control policy documents, and medical insurance agreements, etc.
From the perspective of trends, it is mainly reflected in the "three modernizations": First, normalization. Since 2019, unannounced inspections have been organized and carried out continuously at the national and provincial levels, achieving full coverage of provinces, autonomous regions and municipalities. Based on the severe situation of medical insurance fund supervision at present and in the future, unannounced inspections, as an important way to treat both the symptoms and root causes, still play an important role in maintaining a high-pressure regulatory situation. The second is standardization. The "Regulations on the Supervision and Administration of the Use of Medical Security Funds" has put forward new and higher requirements for unannounced inspections, and there is an urgent need to work hard to improve the inspection process, refine inspection standards, and standardize inspection procedures. The third is specialization. Unannounced inspection is a process that relies on scientific and professional methods to discover problems. Faced with the reality of a large number of regulatory objects and a long chain, it is even more inseparable from the use of modern information technology to carry out precise inspections and the joint efforts of a capable professional inspection team. .
2. Welcome carefully
Paying attention to preparation for inspection and carefully welcoming inspection are the proper meanings of carrying out unannounced inspection. For the unannounced inspection to be carried out smoothly and achieve effective results, it requires the strong support of the local medical insurance department and the active cooperation of the inspected subjects. Specifically, it is necessary to implement the "three major tasks":
The first is to fully cooperate. This is the basic requirement for colleagues to conduct unannounced inspections. The medical insurance department at the place of inspection and the subjects under inspection should each perform their duties and fulfill their responsibilities in accordance with the principle of "not overstepping their limits in performing their duties, not being out of touch in guaranteeing, and not interfering in inspections." Among them, the medical insurance department needs to assist in timely extraction of medical insurance data, provide local medical insurance policies and systems (including medical insurance agreements, reimbursements, cost control and other documents), and clearly connect liaison personnel; the subject should truthfully provide hospital data and information (financial accounts, medical records, Records of entry and exit of drugs and medical consumables, instructions for inspection and inspection equipment, etc.), and make preparations for office work, inquiries, inspections, etc. required for on-site inspections.
The second is active interaction. This is a higher standard for colleagues to conduct unannounced inspections.
The medical insurance department in the place being inspected should adhere to the principle of "participation without judgment", proactively strengthen communication with inspection team members, introduce the differences in local medical insurance policies and systems in a targeted manner, actively respond to inspectors' inquiries, and allow the inspection team to fully understand the situation; in addition, , with the consent of the inspection team, the backbone of the local medical insurance supervision business can be dispatched to observe the unannounced inspection process, and with the help of the unannounced inspection practice platform, local fund supervision professionals can be cultivated and trained. The subjects under inspection should truthfully answer questions about diagnosis, treatment, medication and other aspects consulted by the inspectors, provide evidence-based, scientific and responsible explanations, and strictly ensure that the facts are not subjective and do not avoid problems when faced with them.
The third step is to make immediate changes. This is an important requirement for colleagues to conduct unannounced inspections. Regarding the qualitative and quantitative problems of medical insurance violations pointed out during the inspection, the medical insurance department in the place where the inspection was conducted should strengthen political responsibility, promptly follow up and verify the problems, carefully analyze the causes of the problems, and supervise the implementation of rectification responsibilities. While checking the list of claimed problems, the subjects under inspection should establish a strong awareness of rectification and quickly propose effective measures to "stop losses and fix leaks" to prevent "making mistakes while checking and making mistakes again and again"; they should step up efforts to investigate all types of illegal and illegal use of medical insurance funds. Sort out the problems, clarify the rectification responsibilities and completion time limits of departments and personnel, and prevent "prolonged delays and unresolved issues"; dare to deal with people and matters that are against the trend of defrauding insurance in an inward and serious manner, and prevent "using education to supervise, and using education to supervise management". "Control instead of punishment".