The medical institutions and retail pharmacies referred to in these Measures are those medical institutions and retail pharmacies that have signed agreements on basic medical services with the basic medical insurance administrators.
The participants referred to in these measures are those who pay the basic medical insurance fees and enjoy the basic medical insurance benefits in accordance with the regulations. Article 3 The medical insurance department is responsible for the supervision of basic medical insurance services.
Development and reform, finance, audit, health, drug supervision and other competent departments shall do a good job in the supervision of basic medical insurance services within their respective areas of responsibility. Article IV medical institutions shall strictly implement the national and autonomous regions of the basic medical insurance drug directory, diagnosis and treatment items directory, the scope of medical service facilities and medical consumables payment standards directory and other provisions, the implementation of the basic medical service agreement, for the insured to provide reasonable and necessary medical services. Article 5 The retail pharmacies shall comply with the regulations on drug prices and basic medical insurance policies, fulfill the basic medical insurance service agreement, and provide prescription drugs dispensing and non-prescription drugs purchasing services for the insured. Article 6 The basic medical insurance agency shall fulfill the basic medical insurance service agreement, publicize the handling procedures, and establish and improve the business, financial, security and risk management system.
Basic medical insurance agencies shall, at least once a year, publicize information on major indicators such as average hospitalization costs and growth rates, average hospitalization reimbursement ratios, and ratios of non-basic medical insurance costs to hospitalization costs, all of which are within the scope of payment by the basic medical insurance fund. Article 7 The commercial insurance organizations that underwrite the major disease insurance and the financial institutions that undertake the settlement and payment of the basic medical insurance expenses shall, in strict accordance with the provisions of the agreement, provide convenient, fast and considerate services for the medical institutions, retail pharmacies and the insured persons. Article 8 The insured shall be honest and trustworthy, and comply with the laws and regulations and policies on basic medical insurance. Article 9 Medical institutions, retail pharmacies and basic medical insurance agencies shall not engage in the following acts of fraudulently obtaining expenditure from the basic medical insurance fund:
(1) Providing false diagnostic certificates of illnesses, medical records, prescriptions and medical bills, etc., to fraudulently obtain expenditure from the basic medical insurance fund;
(2) Allowing non-participating persons to seek medical treatment in the name of the insured persons;
(3) (iii) Allowing the use of the basic medical insurance fund to pay for medical expenses that should be paid by the participants at their own expense;
(iv) Allowing the use of basic medical insurance vouchers to purchase drugs or non-medical supplies that are not covered by the basic medical insurance fund;
(v) Adopting the practice of falsely recording expenses, or stringing together or exchanging non-Medicare-paid items for items paid for by the medical insurance fund;
(vi) Exceeding the standard charges or (vii) realizing participants' individual medical insurance fund accounts by fictitious purchase of medicines;
(viii) misusing large equipment for examination and expensive medicines or providing other unnecessary medical services to participants not in accordance with the needs of their medical conditions;
(ix) transferring medical insurance service terminals for use by or on behalf of non-agreed service units;
(x) using medical insurance individual accounts on behalf of non-agreed service units;
(xi) using medical insurance individual accounts on behalf of non-agreed service units. agreement service units to use the medical insurance individual account fund for settlement;
(j) Expenditure of basic medical insurance premiums knowing that they are false reimbursement vouchers;
(k) Other acts of fraudulent expenditure of the basic medical insurance fund. Article 10 Participants shall not engage in the following acts of fraudulently obtaining basic medical insurance benefits:
(1) providing one's basic medical insurance voucher to another person or a medical institution for use;
(2) fraudulently using another person's basic medical insurance voucher to seek medical treatment;
(3) falsifying or altering medical records, prescriptions, certificates of diagnosis of diseases and medical bills;
(4) Other acts of cheating basic medical insurance benefits. Article 11 Employing units shall comply with the laws and regulations on basic medical insurance and relevant provisions, and shall not issue false medical certificates for insured persons to help them obtain basic medical insurance benefits fraudulently. Article 12 The medical insurance department shall, through the basic medical insurance monitoring information system, carry out real-time monitoring of the medical treatment services of medical institutions and retail pharmacies, as well as the medical treatment of insured persons and the settlement of medical fees by the basic medical insurance administration organization. Article 13 medical institutions, retail pharmacies should strengthen the construction of information technology, the implementation of electronic medical records, drug catalogs, diagnosis and treatment items and other aspects of information management, to ensure that its information system and the basic medical insurance agencies fee settlement system, the basic medical insurance monitoring information system interconnection and interoperability.
Medical institutions, retail pharmacies and basic medical insurance agencies shall timely and accurately upload diagnosis and treatment and cost settlement and other relevant information to the basic medical insurance information system. Article 14 Any unit or individual has the right to report and complain about the violation of basic medical insurance regulations. The medical insurance department shall promptly investigate and deal with the matter, and reply in writing to the informant or complainant with the results of the investigation. Article 15 The medical protection department through real-time monitoring, receiving reports and complaints, medical institutions, retail pharmacies, basic medical insurance agencies and participants suspected of violating the basic medical insurance provisions of the investigation and verification.
When investigating and verifying suspected violations of the basic medical insurance regulations, the medical insurance department shall present a valid law enforcement document, and may take the following measures:
(1) inspecting, recording, and copying information related to the income and expenditure and management of the basic medical insurance fund, and sealing any information that may have been transferred, concealed, or lost;
(2) questioning units and individuals related to the matter under investigation. Investigation matters related to the units and individuals, requiring them to make explanations on issues related to the investigation matters, provide relevant supporting materials;
(3) fraudulent use of the basic medical insurance fund or treatment behavior to be stopped and ordered to make corrections.