What does medical insurance flight inspection mean?

The flight inspection system of medical insurance refers to the on-site supervision and inspection by the administrative department of medical insurance on the use of medical insurance funds by medical insurance agencies, medical bidding and purchasing institutions, designated medical institutions, pharmaceutical enterprises, medical insurance physicians (pharmacists) and insured persons without prior notice. The system has the following characteristics: First, it is legal and functional, and it is usually an administrative act authorized by the superior medical insurance administrative department according to the Social Insurance Law, the Administrative Enforcement Law, the Provisions on the Functional Allocation, Internal Organizations and Staffing of the National Medical Insurance Bureau, and the Provisions on the Supervision of Flight Inspection of Medical Insurance Fund (Trial), which is implemented on its own initiative without the application of the supervision and inspection unit; Second, directness, the medical insurance administrative department directly faces the on-site inspection of people, things, behaviors and places; Third, flight inspection is usually carried out in secret, that is, the medical insurance administrative department does not inform the inspected object in advance; Fourth, it is mandatory. If the inspected object forges, alters, transfers, conceals, falsifies or destroys financial accounts, accounting vouchers, prescriptions, medical records, treatment and inspection records, expense details and the warehousing and warehousing records of drugs and medical devices, the medical insurance administrative department has the right to take compulsory measures. When the inspected object does not cooperate, refuses or hinders the medical insurance administrative department from carrying out the inspection, the medical insurance administrative department may carry out compulsory inspection, and the inspected object will bear corresponding legal responsibilities; Fifth, objectivity. The administrative department of medical insurance may invite health, public security, drug supervision and other departments to jointly fly the inspection, and organize qualified social third parties to participate in the inspection by purchasing services. According to the needs of inspection work, news media can be invited to participate in supervision; Sixth, it is invasive. Flight inspection will bring adverse consequences to the inspected object, that is, set the obligation of the inspected object to accept on-site inspection, retain information and accept inquiries, limit the relative rights and interests of places, personnel and information within a certain period of time, and implement administrative compulsory measures.

1. Under what circumstances can flight inspection be carried out?

There are five situations in which the administrative department of medical security can initiate the implementation of flight inspection, including:

(1) is arranged in the annual work plan;

(two) the clues to report complaints reflect that there may be major security risks in the medical security fund;

(3) Intelligent monitoring of medical security suggests that there may be major security risks in the medical security fund;

(4) news media exposure, causing significant social impact;

(5) Other circumstances requiring flight inspection.

For the flight inspection arranged in the annual work plan, the administrative department of medical security shall organize the implementation in the form of "double random and one open".

In addition, due to reporting complaints, intelligent monitoring, news media exposure, etc. , may cause significant financial security risks or have a significant social impact, as well as the need for confidentiality, you can directly carry out inspection work.

Second, how to organize flight inspection?

The national medical security administrative department is responsible for organizing and implementing national flight inspection. The provincial medical security administrative department is responsible for organizing and implementing the flight inspection within its administrative area. In addition, the provincial medical security administrative department may conduct joint and cross-flight inspections, but it shall file with the national medical security administrative department in advance.

The administrative department of medical security can invite health, traditional Chinese medicine, finance and other relevant departments to jointly carry out flight inspection, and can also hire qualified third-party institutions and professionals such as information technology service institutions, accounting firms and commercial insurance institutions to assist in flight inspection.

The administrative department of medical security shall establish a library of inspected objects, a library of flight inspection team leaders, an inspector library and an expert database, and implement dynamic management according to the inspected objects, personnel changes and personnel evaluation.

The administrative department of medical security shall determine the list of the inspected objects, flight inspection team leaders, inspectors and experts, leaving traces throughout the process and tracing the responsibilities.

The administrative department of medical security that organizes flight inspection shall make overall arrangements, do a good job in security, and send a flight inspection team to carry out on-site inspection.

The flight inspection team consists of medical security administrative law enforcement personnel authorized by this inspection and other personnel familiar with medical insurance, medicine, finance, information and other related majors.

The medical security administrative department of the inspected province (city) shall cooperate with the flight inspection, provide true, complete and accurate policy documents, data information and other related materials in a timely manner, and send administrative law enforcement personnel to participate in the on-site inspection.

Third, the application of flight inspection results

The flight inspection team shall formulate a specific implementation plan for flight inspection, clarify the inspection focus, methods and procedures, take the initiative to judge risks, and propose prevention and control plans as appropriate. How to use the results of various problems found in flight inspection is related to the effectiveness of flight inspection. This method clarifies that the medical security administrative department of the inspected province (city) shall handle different cases of suspected violation of laws and regulations in accordance with the corresponding authority and procedures, such as:

(a) in violation of the medical insurance service agreement, the medical insurance agency shall handle it according to the agreement;

(two) in violation of the relevant laws, regulations and rules of medical security, administrative punishment shall be given according to law;

(3) handing over to the discipline inspection and supervision organs the clues of party member, the object of supervision or the responsible comrades of designated medical institutions, medical insurance administrative departments, medical insurance agencies and other units who are suspected of violating discipline, violating duties or committing crimes;

(four) suspected of violating relevant laws, regulations and rules, which should be handled by other departments, shall be transferred to the corresponding departments for handling;

(five) other circumstances that need to be dealt with, according to the corresponding provisions.

In addition, in view of the regional, universal or long-term problems found in flight inspection, the person in charge of the medical security department where the inspected object is located can be interviewed.

legal ground

People's Republic of China (PRC) social insurance law

Article 76 The standing committees of people's congresses at various levels shall hear and consider the special work reports of the people's governments at the corresponding levels on the revenue and expenditure, management, investment operation and supervision and inspection of social insurance funds, organize law enforcement inspections on the implementation of this Law, and exercise their supervisory functions and powers according to law.

Article 77 The social insurance administrative department of the people's government at or above the county level shall strengthen the supervision and inspection of the employers and individuals' compliance with social insurance laws and regulations.

When the administrative department of social insurance carries out supervision and inspection, the employer and individual under inspection shall truthfully provide information related to social insurance, and shall not refuse to inspect or make false reports or conceal.

Article 78 The financial department and the auditing organ shall, according to their respective functions and duties, supervise the income and expenditure, management and investment operation of social insurance funds.