National health insurance flyover has been launched, can cover the fixed-point pharmacy src="/mmbiz_jpg/ I4xZibFESHM07nB7xhwkqcCNA8zY80RBYqrlHdO2fxxR5Fmd7kOg39B6PsP5kaz5QZ0FBTic6CRicuMYicrbdXlUUA/640?wx_fmt=jpeg"/>National Health Insurance Fly-In
National Health Insurance Fly-In
National Health Insurance Fly-In
National Health Insurance Fly-In
The National Health Insurance Flying Test has been launched.
Coverage of designated pharmacies
A few days ago, the Central Commission for Discipline Inspection of the State Supervisory Commission website posted that the flight inspection team staff has been stationed in Yunnan, and to carry out the 2022 health insurance fund flight inspection. According to the requirements of the Notice on the Flight Inspection Work of the Medical Insurance Fund for the Year 2022 issued by the National Health Insurance Bureau (NHIB) on May 31, the NHIB, the Ministry of Finance, the National Health Commission, and the State Administration of Traditional Chinese Medicine (SATCM) will jointly organize and carry out the flight inspections of the medical insurance fund in the second half of this year, covering all 31 provinces of the country. The document mentions that the health insurance flight inspection will check the time frame framed since January 1, 2020, the use of the health insurance fund (i.e., reverse check the use of the health insurance fund during the past two and a half years). In addition, the health insurance flying inspection object for the national fixed-point medical institutions, county and district-level health insurance agencies, while depending on the situation can be extended to check the relevant institutions and participants. This means that the local authorities can take the designated pharmacy as a flying target. According to past experience, the designated pharmacy inspection content is usually "three strict prohibitions" and "five norms" - strictly prohibit the theft of medical insurance vouchers, strictly prohibit the extraction of personal accounts, strictly prohibited to provide The five norms are usually "three prohibitions" and "five norms" - forbidding the theft of medical insurance vouchers, forbidding the use of personal accounts, forbidding the provision of false invoices and standardizing the management of purchase and sale, standardizing business projects, standardizing the information system, standardizing the behavior of the service, and standardizing the drug registration. Cypress Blue - pharmacy manager combed and found that the local departments announced the designated pharmacy inspection focus, mainly contains the following 14 aspects. 1. Whether to comply with the medical insurance designated retail pharmacy set conditions, whether to carry out the fight against fraudulent insurance publicity, in the store to form a publicity atmosphere. 2. Drugs and non-drugs, prescription drugs and non-prescription drugs, external drugs and internal drugs are categorized and managed in separate areas, and there are distinctive signs. 3. Whether the pharmacist or licensed pharmacist is on duty during the business period, and whether there are forged or altered prescriptions for the sale of drugs. 4. Whether the sale of prescription drugs in violation of the law, must be sold with a prescription for prescription drugs, whether to obtain and retain the prescription or medical records. 5. Whether through the exchange of drugs, supplies, goods and other fraudulent health insurance funds. 6. Whether the scope of business. 7. Whether the operation of fake and shoddy drugs, whether there is a network of illegal sales of drugs. 8. Whether the purchase of drugs from illegal channels, illegal recovery of drugs and packaging. 9. Whether the records of drug purchase, receipt, acceptance, sales, etc. are entered into the computer system, the computer system data is true, complete and traceable. 10. Refrigerated frozen drugs cold chain transportation, storage and other requirements. 11. Whether the illegal sale of prescription drugs, illegal operation of drugs containing stimulants. 12. Whether to use the national unified medical insurance code according to regulations. 13. Whether the electronic health insurance vouchers are used normally. 14. Whether the drugs are dispensed for other pharmacies that are not part of the same chain, or whether the card is used for settlement by non-designated pharmacies or other organizations.Pharmacy string drug fraud
Medicare department refused to pay 2.54 million yuan
This year, in order to reduce the phenomenon of pharmacies fraudulent health insurance fund, the State Medical Insurance Bureau announced a number of typical cases.
On May 28, the National Health Insurance Bureau released 10 cases of fraudulent insurance cases, all related to designated pharmacies. Among them, a chain of pharmacies in Jilin, through the exchange of drugs, the health insurance fund of nearly 2.54 million yuan. The local health insurance department decided to refuse to pay the illegal use of health insurance funds, and the lifting of the health insurance service agreement, the chain of pharmacies shall not apply for health insurance qualification within three years. In addition, a pharmacy in Zhejiang Province, due to the illegal use of about 170,000 yuan of health insurance funds, was sentenced to double the default fine of about 340,000 yuan. Not only the State Medical Insurance Bureau, the local medical insurance department for the pharmacy insurance fraud, but also exposed a number of typical cases. Recently, the Heilongjiang Health Insurance Bureau informed the 10 typical cases, in which a chain of pharmacy stores through the non-designated institutions card way to fraudulent health insurance funds. The health insurance department in accordance with the relevant provisions of the recovery of health insurance fund yuan, and cancel the pharmacy health insurance service agreement. In August of this year, Hubei Daily reported that Xiaogan City Commission for Discipline Inspection and Supervision Commission and health insurance, market supervision, public security and other departments set up a "three false" special inspection team to take the form of unannounced unannounced visits to investigate hospitals, pharmacies, and other designated medical institutions to fraudulent insurance issues. So far, the special inspection team has dealt with 225 designated medical institutions, has recovered the principal of the health insurance fund million yuan, liquidated damages million yuan, administrative penalties million yuan, other penalties million yuan. In June of this year, Jiangsu Yancheng City Health Insurance Bureau exposed a number of cases of insurance fraud, in which a pharmacy there are actual sales and sales inventory management data inconsistent with the violations, violations of the amount of yuan, by the health insurance department to make the following treatment: 1. Recovery of the amount of violations of the yuan; 2. and impose liquidated damages of yuan. For pharmacy operators, in order to avoid penalties, to distinguish the pharmacy "insurance fraud" behavior is very necessary. To this end, the Chongqing Health Insurance Bureau summarized the following seven kinds of pharmacy "insurance fraud" behavior: 1. Will be paid outside the scope of the health insurance fund items into the health insurance fund settlement. 2. By creating a false project to obtain funds. 3. Provide non-designated retail pharmacies with card-issuing services or include the costs incurred by non-designated retail pharmacies in the settlement of the health insurance fund. 4. For participants to swap drugs, consumables, items and other fraudulent health insurance fund expenditure. 5. To provide false invoices or false invoices for the insured. 6. Inducing participants to buy cosmetics, household goods and other items outside the scope of payment of the medical insurance fund. 7. Other behaviors prohibited by laws, regulations and agreements.Reporting pharmacy fraud
Maximum award of 100,000
In order to better address the problem of fraudulent designated pharmacies, medical institutions, in addition to the government agencies, the State also encourages the introduction of social supervision forces.
In December 2021, the National Health Insurance Administration's "Management Measures for Flight Inspection of Medical Insurance Fund (Draft for Public Comments)" mentioned that where the reported complaint clues reflect that there may be significant security risks to the medical insurance fund, and where news media exposure has caused significant social impact, the medical insurance department can implement flight inspection. 2022 March 1 implementation of the "Interim Measures for the Supervision and Management of the Use of Medical Insurance Fund Reporting and Processing" emphasizes that all levels of medical insurance administrative departments should be open reporting channels, strengthen the reporting channel specialization, integration of the construction; the investigation and verification of the report meets the reporting requirements of the report, the administrative department of health care insurance should be rewarded in accordance with the provisions of the report. As for the "insurance fraud" reporting incentives, many clear whistleblower maximum reward of 100,000 yuan. For example, the Xinjiang Health Insurance Bureau recently announced that it encourages the general public to actively monitor and report "fraudulent use of information on the insurance of dead people to fraudulent insurance" phenomenon, the report has been verified, the whistleblower can get a maximum of 100,000 yuan reward. In August this year, Ziyang City, Sichuan Health Insurance Bureau, Finance Bureau jointly issued a document welcoming the masses of people to report fraudulent insurance behavior, the investigation, the eligible informants will be rewarded, the amount of reward up to 100,000 yuan per case.