Interim Measures for Reporting and Rewarding Fraudulent and Fraudulent Acts of the Medical Security Fund> the Notice"(Medicare Office Fa [
2018]22No.) and other provisions, is hereby to further improve the The city's health insurance designated medical institutions management matters are notified as follows:
A. Adjustment of the application conditions In accordance with the principles of openness, fairness, convenience and efficiency, the health insurance designated medical institutions to adjust the application conditions. Medical institutions applying for health insurance designated agreement management should meet the following basic conditions: (a) designated medical institutions 1, compliance with pharmaceutical services, pharmaceutical prices, social insurance and other relevant laws and regulations and policies, the date of application for six months before the market supervision, health, human and social sectors have not been subjected to administrative penalties. 2, with a "medical institution license" or "Chinese medicine clinic record certificate", and the corresponding "business license" ("business legal person registration certificate" or "certificate of registration of private non-enterprise units"). 3, premises, medical staff, equipment and other settings must comply with the relevant provisions of the health sector, the business address should be consistent with the "business license" (Certificate of Registration of Business Legal Entity or Certificate of Registration of Private Non-Enterprise Units) the information contained therein. Not required by law and did not apply for the above license, the business address should be with the "Medical Practice Permit" or "Chinese medicine clinic record certificate," the information contained in the same. 4, the commitment to health insurance designated after the implementation of health insurance policy, the establishment of a sound medical service management system, including medical insurance physician management assessment system, equipped with basic health insurance management services need to meet the needs of the relevant personnel and equipment, information systems. 5, the development and implementation of complete and standardized drugs, medical materials, such as "purchase, sale and inventory" system and financial management system, to ensure that the medicines in the medical insurance directory of the preparation and use of medicines, to ensure that the insured persons to comply with the enjoyment of the treatment. Establishment and normal operation of real-time information management system to provide "purchase, sale and inventory", while preserving the relevant information and records for inspection. 6, the commitment to the medical insurance fixed point in the card settlement system and dispensing area within the visual range of the installation of audio and video monitoring system, to the medical insurance administration and medical insurance agencies to open up the appropriate permissions, to facilitate real-time view or access after the fact. 7, and practitioners signed labor contracts in accordance with the law, according to the provisions of the participation and payment of social insurance. The medical institutions of the sub-institutions, collaboration (cooperation) hospitals should apply separately for medical insurance designated agreement management. (B) designated retail pharmacies 1, to comply with drug management, price management, social insurance and other relevant laws and regulations, the establishment of a relevant management system, the application of the first six months of the market supervision, the human resources and social services departments and other administrative penalties. 2, with the "drug business license" and the corresponding "business license" and drug quality management standard certification (GSP). 3, the place, equipment and other settings must be in line with the relevant provisions of the market supervision department, business address and "business license" information contained in the same. 4, equipped with not less than two pharmacists (Chinese pharmacist), of which at least one licensed pharmacist, licensed pharmacist, pharmacist shall not be titled (verification of its registration certificate, social insurance certificates and labor contracts and other relevant materials), to ensure that at least one pharmacist on duty during business hours. The operation of Chinese herbal medicine pharmacy, should be equipped with a Chinese pharmacist above the technical title of Chinese medicine professionals and technicians. 5, the development and implementation of complete and standardized permitted sales of drugs, such as "sales and inventory" system and financial management system. The establishment and operation of real-time information management system to provide "sales and inventory", while preserving the relevant information and records for inspection. 6, the commitment to health insurance fixed point in the card settlement system and dispensing area within the visual range of the installation of audio and video monitoring system (approved by the relevant departments while operating health products and other commodities, placed in the area, settlement counters, settlement system set up, audio and video system can cover), to the health care administration and health care agencies to open up the appropriate permissions to facilitate real-time view or access after the fact. 7, and practitioners signed labor contracts in accordance with the law, in accordance with the provisions of the participation and payment of social insurance. Drug retail chain stores should apply for a separate health insurance designated organizations. Second, the establishment of access to the negative list system medical insurance agency for one of the following circumstances of the medical institutions, within a certain period of time will not accept its application for medical insurance designated: (a) provide false application information in the application process to provide false information on the medical institutions and their legal representatives, the main investors, from the date of verification, the medical insurance agency to record its breach of trust and send it to the public at the local level *****. The company's credit platform will be pushed to the public ****, and will not accept the application of the medical institution for three years. (B) has been terminated by the health insurance service agreement fixed-point medical institutions were terminated by the health insurance service agreement, including the termination of the service agreement to change the name, business premises address and legal representative or person in charge of the (based on the registration records of the licensing authority and related documents), from the date of termination of the health insurance service agreement within three years, the health insurance agency will not accept their applications. (C) included in the list of bad faith medical institutions and their legal representatives, the person in charge of a serious breach of trust (based on the results of the query of the public **** credit platform at this level), the health insurance agency does not accept its application for medical insurance points. Third, standardize the workflow and rules The health insurance agency should be issued through the government website and other forms of publicity to announce the health insurance designated medical institutions to apply for conditions, the need to provide materials and forms, acceptance of applications for the agency and the time, location, mode, workflow and so on. The medical insurance agency shall establish an internal work management system, make the corresponding form, to do the whole process of traceability and fairness, openness and impartiality. Workflow and rules in accordance with the following provisions: (a) voluntary application, registration and acceptance 1, meet the fixed-point agreement to manage the application conditions, voluntarily undertake the basic medical insurance services to the local medical insurance agency to submit a written application, while submitting the required materials. Yangzhou city within the scope of the medical institutions to the city health insurance agency to submit a written application, the counties (cities) within the scope of the medical institutions to the local health insurance agency to submit a written application. 2, the medical insurance agency should be declared to the medical institutions to register the material in a timely manner. Declaration materials are complete and comply with the prescribed form, the health insurance agency from the date of registration within five working days to issue a certificate of acceptance; declaration materials are incomplete or do not meet the prescribed form, it should be the field or within five working days of a one-time written notice to the applicant needs to make corrections to all the contents of the applicant in writing to inform the receipt of the five working days from the time of receipt of the corrections are not regarded as withdrawal of the application. 3, one of the following circumstances, the health insurance agency does not accept the application of medical institutions of the health insurance agency, and informed of the reasons for inadmissibility according to the regulations: does not meet the basic conditions and standards for the management of fixed-point agreement; not in accordance with the specified time and content of the declaration of the relevant materials, declaration of incomplete materials or do not comply with the prescribed form; belong to the negative list of access to the circumstances listed. (B) material review, on-site review medical insurance agencies to submit the declaration of medical institutions for preliminary examination, the preliminary examination of opinions. Qualified units of the preliminary examination, on-site review. (C) comprehensive assessment, collective deliberation The medical insurance agency shall set up a medical insurance designated medical institutions assessment team (hereinafter referred to as the assessment team), according to the medical insurance designated application conditions, combined with the materials of the preliminary examination and on-site review, the application of the medical institutions to assess. The assessment team is composed of relevant experts, industry associations, insured units and insured persons***. The evaluation team in Yangzhou city was sent by the city and district health insurance organizations*** to participate in the same. The list of proposed new fixed-point medical institutions considered and approved by the evaluation team will be publicized by the medical insurance agency. (D) social publicity, negotiation contract 1, to be added to the list of fixed-point medical institutions through the local health insurance administrative department and health insurance agency government website publicity for a week. On the publicity period of the public and the assessment team to verify that does not meet the conditions of the medical insurance fixed-point application of medical institutions, from the proposed new list to be removed; on the publicity period of no objection or although there are objections to the verification of reflecting the situation of the medical institutions is not true, by the medical insurance management agency to issue a document announcing the results of the assessment of the management of the medical insurance fixed-point agreement. Evaluation results only for the medical insurance agency to sign the agreement to use. 2, the medical insurance agency to take into account the service capacity and characteristics of the medical insurance fund support capacity and information system construction, as well as the intention of the insured person to seek medical treatment and other factors, and the pharmaceutical organization of equal communication, consultation and negotiation. The two sides signed a service agreement after consensus, to determine the management relationship of health insurance designated agreement. Pharmaceutical institutions in the signing of the service agreement, must be issued at the same time a written credit commitment to ensure that law-abiding business, integrity and compliance in the future agreement period to comply with all laws and regulations related to the management of the designated medical institutions and policies.If a pharmaceutical organization fails to sign the agreement within the agreed date, it is considered to be an automatic waiver. If no agreement can be reached, the agreement will not be signed. If a pharmaceutical organization that has not signed a service agreement applies for a health insurance designation, it will need to re-apply and re-evaluate.
3. The time limit from the date of acceptance to the completion of the negotiation and signing of the time limit, in principle, does not exceed 60 working days. Special circumstances require an extension of the time limit, subject to the approval of the administrative department of health insurance at the same level. 4, outpatient special diseases and special drugs designated medical institutions in the designated medical institutions have been preferred. Fourth, to strengthen the supervision of designated medical institutions (a) strengthen the daily agreement management The coordinating area in accordance with the principle of territorial management, is responsible for the daily agreement management of designated medical institutions in the area under their jurisdiction. Each year, the county (city) health insurance agencies need to summarize the region's fixed-point agreement management of pharmaceutical institutions health insurance service information reported to the same level of health care administrative department for the record, the city health insurance agencies and county (city) health care administrative department reported to the municipal health care administrative department for the record. 1, improve the service agreement text. Municipal health insurance agencies are responsible for the preparation of the city's unified service agreement format text, and according to health insurance policy and management needs to be adjusted in due course. In the agreed designated medical institutions responsibilities and obligations, standardize the overall quality of its medical services and requirements at the same time, but also to reflect the responsibilities and obligations of practitioners. Default practitioners, depending on the circumstances of the implementation of appropriate measures up to the suspension or termination of their medical insurance real-time settlement service program, and the medical services provided by the refusal to pay fees. Each (county, city) health insurance agency can be based on the municipal text content, combined with the local reality of supplementing the content of the relevant service agreement. 2, the agreement is valid for a short, long-term combination. The first signing of the agreement is generally valid for no more than 2 years. After the expiration of the agreement, the fixed-point medical institutions in the agreement period without illegal, illegal behavior, the renewal of the agreement is valid for 3 years -5 years (the specific length of time by the local agencies to decide on their own, but the same co-ordination area within the renewal of the agreement validity period needs to be consistent); fixed-point medical institutions in the agreement period of illegal, illegal behavior, but has not been lifted from the agreement, the renewal of the agreement validity period of 1 year. 3, the establishment of designated medical institutions to change the health insurance service information audit filing system. Designated medical institutions health insurance service information changes, must provide "medical institutions license" ("Chinese medicine clinic record certificate"), "drug license") and the corresponding "business license" ("business registration certificate" or "private non-enterprise unit registration certificate") original and copy. If any of these licenses are canceled, re-registered or re-approved, according to the new health insurance agency procedures. (1) designated medical institutions need to change the name, the person in charge, licensed pharmacists, etc., must be changed within 15 days after the change, with a written application for change, has changed the registration of the original and copies of documents, etc., to the health insurance agency for health insurance services to change the audit procedures. The designated medical institutions did not handle or late for the above health insurance service information change audit procedures, in accordance with the service agreement agreed to deal with the situation. (2) designated medical institutions need to change the business address or legal representative (operator), should be informed in writing 15 days in advance of the integrated area of the health insurance agency, and within 15 days after the change of license, with a written application for change, has changed the registration of the original and a copy of the license and other materials, to the health insurance agency to handle the change of the health insurance service information audit procedures, the original agreement will be terminated. The medical insurance management organization will handle the medical institution according to the procedure of the new medical insurance designated institution. The fixed-point medical institutions did not handle or late for the above health insurance service information change audit procedures, the original agreement will be terminated. (3) The health insurance agency should be timely to change the fixed-point medical institutions to review the health insurance service information reported to the same level of the administrative department of health insurance for the record. 4, the implementation of the fixed-point medical institutions labeling system. The designated medical institutions should be in a prominent position in the business premises hanging basic medical insurance designated agreement management of pharmaceutical institutions signage, to facilitate public recognition. Signage style and specifications by the municipal health insurance agency unified regulations. 5, the establishment of a perfect medical cost intelligent audit system. Health insurance agencies to standardize the intelligent audit data indicators, expand the application of clinical rules, improve the breadth of intelligent audit, accuracy and precision, give full play to the effectiveness of the intelligent audit system, provide timely audit prompt information to the designated medical institutions to realize the tips beforehand, in the event of monitoring and early warning and after the responsibility for the traceability, standardize the behavior of medical services. 6, the establishment of assessment and evaluation system. Medical insurance agencies to establish and improve the designated agreement management of medical institutions assessment and evaluation and dynamic management mechanism, in the medical insurance service agreement to clarify the circumstances of violation and breach of contract and processing rules. To carry out daily inspections and case review work, open up reporting and complaint channels, the problems found in strict accordance with the agreement and assessment methods. (B) the implementation of the exit mechanism of the fixed-point medical institutions fixed-point medical institutions in the following behaviors, all the service agreement: 1.fraudulent fraudulent access to the medical insurance fund ; 2. agreement validity of the agreement for a cumulative total of three times to be suspended or Suspension of the agreement during the time limit is not required to rectify or rectification is not in place; 3. Suspended "medical practice license" or "Chinese medicine clinic filing certificate" or "business license" (Certificate of Registration of Public Legal Entity or "Certificate of Registration of Private Non-Enterprise Units"); 4. Refuse to refuse, obstruct, or do not cooperate with the health care administration or health care insurance agency to carry out the necessary supervision and inspection; 5. False information and other improper means to become a fixed-point medical institutions were found; 6. Other serious consequences or major impact of illegal, non-compliant behavior. The fixed-point retail pharmacy in the following behaviors, all terminated the service agreement: 1.fraud and fraudulent access to the medical insurance fund ; 2. Agreement validity period of a total of three times the agreement was suspended or suspension of the agreement during the time required to rectify the requirements of the time limit or rectification is not in place; 3. Suspended the "Drug Business License" or "business license"; 4. Refuse to cooperate with the medical insurance administrative department or the medical insurance administration. Cooperate with the health insurance administrative departments or health insurance agencies to carry out the necessary supervision and inspection; 5. Take the provision of false information and other improper means to become a designated retail pharmacy was found; 6. Other serious consequences or major impact of illegal, non-compliant behavior. The medical insurance agency in the formulation of the text of the service agreement, agreed to terminate the service agreement should include, but not limited to, the above provisions. (C) strengthen the supervision and inspection of administrative law enforcement The competent administrative department of the local health insurance should take regular, irregular supervision, health insurance agencies, designated medical institutions to implement the health insurance policy, the agreement signed and the implementation of the agreement to carry out supervision and inspection of violations of laws and regulations of health insurance should be ordered to rectify the behavior, and the implementation of administrative penalties according to the law; involves the responsibilities of other administrative departments, transfer to the relevant departments; suspected of criminal activity, and the relevant departments. The government has been working on this issue for a long time, but it has not been able to do so yet. To broaden the supervision channels, innovative supervision methods, explore through the participants satisfaction survey, the introduction of third-party evaluation, the hiring of social supervisors and other ways to mobilize all sectors of society to participate in the supervision of medical insurance. (D) effective convergence of administrative supervision and agreement management The agency in the implementation of the daily management of the agreement, found that the fixed-point medical institutions there is a breach of contract, illegal behavior, according to the agreement to deal with the agreement (the results of the processing of the same level of health care administrative department for the record), at the same time, the clues to the violation of law should be transferred to the competent authorities of the health care administration in a timely manner; health care administration in the implementation of the administrative enforcement of the supervision and inspection, and found the fixed-point medicine institutions there is a violation of law. In the implementation of administrative law enforcement supervision and inspection, found that the designated medical institutions in breach of contract, illegal behavior, according to the law to implement administrative penalties (penalty decision copied to the agency), at the same time, the breach of contract should be referred to the agency to deal with. If necessary, a joint inspection team will be formed to carry out the inspection. Through administrative supervision and agreement management of the effective convergence of the formation of health insurance supervision work, to ensure that the health insurance supervision does not leave a gap, no dead ends. (E) strengthen interdepartmental information sharing The local health insurance administrative departments and health insurance agencies, to take the initiative to strengthen communication with health, drug supervision, market supervision, social security and other departments to establish information *** enjoyment mechanism, the designated medical institutions in the event of medical accidents, the emergence of substandard and counterfeit medicines, fraud and fraudulent insurance, and other major events in a timely manner to notify each other, the implementation of the city's designated medical institutions to deal with violations of the results of the joint mechanism. Mutual recognition of the joint mechanism. (F) strictly guard against integrity risks everywhere to strengthen and improve the basic health insurance internal control system construction, strict internal control system mechanism implementation, health insurance administrative departments, health insurance agencies and staff to effectively comply with the relevant provisions of integrity and self-discipline, and take the initiative to accept the discipline inspection department supervision and social supervision, to prevent corruption from occurring. V. Other matters This notice shall come into force on October 1, 2019, before the city issued the relevant provisions of this notice is inconsistent with this notice, all according to the implementation of this notice. Before the implementation of this notice, the original agreement has been confirmed by the coordinating district health insurance agency and is in effect can continue to fulfill, but the laws, regulations, policies and this notice has new provisions, should be implemented in accordance with the new provisions. If the original agreement is inconsistent with the new provisions, the original agreement shall be revised and supplemented in accordance with the new provisions after consultation between the two parties, and its effect shall be the same as that of the original agreement. The original agreement expires within 30 days before the designated medical institutions to apply for renewal, health insurance agencies should be based on the content of the agreement to negotiate with their consensus can be renewed directly after the agreement. Yangzhou Municipal Bureau of Medical Protection 2019 August 21