Bijie City, supervision and management of the use of medical insurance fund
Chapter I General Provisions
Article I
In order to strengthen the medical insurance fund use of supervision and management. In order to strengthen the supervision and management of medical insurance fund, safeguard fund security, improve the efficiency of fund utilization, safeguard the legitimate rights and interests of citizens' medical insurance, according to the "Chinese People's Republic of China *** and the State Social Insurance Law" "medical insurance fund use supervision and management regulations" and other relevant laws and regulations, combined with the actuality of the city, the formulation of this approach.
Article 2 Bijie integrated area of basic medical insurance (including maternity insurance) fund, medical assistance fund and other medical insurance fund use and supervision and management of these measures.
Article 3 city, county (autonomous counties, cities, districts) people's government (management committee) shall strengthen the supervision and management of the use of medical insurance fund leadership, establish and improve the supervision and management mechanism of medical insurance fund and law enforcement system, strengthen the supervision and management of medical insurance fund team and capacity-building; the establishment of supervision and management of medical insurance fund work Joint meeting system, clear work responsibilities, coordinate and solve major problems in the supervision and management of medical insurance fund use.
Article 4 cities, counties (autonomous counties, cities, districts) medical insurance administrative department is responsible for the administrative region of the medical insurance fund supervision and management work, standardize the medical insurance business, supervise the medical insurance payment scope of medical services and medical expenses, investigate and deal with illegal use of medical insurance fund.
Article 5 city, county (autonomous counties, cities, districts) medical insurance, health, market supervision and management, public security, finance and other departments within their respective areas of responsibility, division of labor, cooperation, establish communication and coordination, case referral and other mechanisms to do a good job of supervision and management of the use of the medical insurance fund. Other departments in their respective areas of responsibility to do related work.
The health sector is responsible for the supervision and management of medical institutions and medical services industry, regulating medical institutions and their medical staff of medical services behavior. Market supervision and management departments are responsible for the supervision and management of health care industry prices, standardize drug business behavior. The financial sector is responsible for standardizing the medical insurance fund budget, financial account accounting, timely disbursement of medical insurance fund, strictly prohibit the misappropriation of medical insurance fund. The public security organs are responsible for investigating and dealing with all kinds of fraud and insurance fraud and other criminal acts.Article 6 cities, counties (autonomous counties, cities, districts) medical insurance administrative department is responsible for the establishment of the medical insurance fund social supervisor system, employing deputies to the National People's Congress, members of the Chinese People's Political Consultative Conference, the news media practitioners to serve as social supervisors, to encourage and support the use of citizens, legal persons and unincorporated organizations of social supervision of the medical insurance fund.
Municipalities, counties (autonomous counties, cities, districts) medical insurance administrative departments are responsible for through the government website, the news media and other channels to the community to publicize the use of medical insurance fund to report violations and complaints contact information.Article 7 medical institutions, pharmaceutical companies (hereinafter collectively referred to as medical institutions) and other units and medical and health industry associations should strengthen industry self-discipline, standardize the behavior of medical services, guide in accordance with the law, the rational use of medical insurance fund.
Chapter II Fund Use
Article 8 medical insurance agencies should strengthen internal control management, establish and improve business, financial, security, information, risk management, and other internal control systems, do a good job in the management of the service agreement, cost monitoring, the fund budget, fund disbursement, Treatment review and payment, financial management, etc., should be regularly announced to the community of the current year's medical insurance fund income, expenditure, balance, etc., to accept social supervision.
Medical insurance agencies should establish collective bargaining and negotiation mechanism with the designated medical institutions, in accordance with the relevant provisions of the state, province and city to determine the designated medical institutions, and the designated medical institutions negotiated and signed a service agreement to regulate the behavior of medical services, clear violations of the service agreement and its responsibility. The medical insurance agency in accordance with laws and regulations and relevant provisions of the fixed-point medical institutions to fulfill the service agreement to carry out cost audits, audit checks, performance assessment. The medical insurance agency shall promptly announce the name and address of the designated medical institution that has signed the service agreement through the official website, public microblogging or the news media after the signing of the service agreement.Article 9 medical insurance agencies should be in accordance with the agreement on the service agreement, in principle, should be declared in the designated medical institutions within 30 working days after the completion of the audit of medical records, the two sides to agree on the results of the audit, and sign the approval of the payment of health insurance costs in line with the provisions of the allocation.
Article 10 designated medical institutions shall establish an internal management system for the use of medical insurance fund, set up a specialized agency for the management of medical insurance or equipped with professional medical insurance management (part-time) staff, according to the basic medical insurance network settlement and intelligent monitoring of the requirements of the network equipment with real-time uploading of information related to health care insurance, the establishment of a sound assessment of the use of medical insurance fund evaluation system. The establishment of a sound system of assessment and evaluation of the use of the fund.
Article 11 fixed-point medical institutions and their staff shall implement the real name of the medical and pharmaceutical management regulations, verification of medical insurance vouchers, in accordance with diagnostic and treatment specifications to provide reasonable and necessary medical services to the insured person truthfully issued bills and related information.
The fixed-point medical institutions should ensure that the costs paid by the medical insurance fund is in line with the prescribed scope of payment; in addition to emergency, rescue and other special circumstances, the provision of medical services outside the scope of payment by the medical insurance fund, should be agreed by the insured person or his close family members, guardians and sign an informed consent form. The medical insurance agency to standardize the management of medical treatment in other places. The designated medical institutions should implement the provisions of hierarchical diagnosis and treatment, and guide the insured to a reasonable and orderly medical treatment.Article 12 designated medical institutions shall, in accordance with the provisions of the financial accounts, accounting vouchers, prescriptions, medical records, treatment and examination records, cost details, medicines and medical supplies in and out of the warehouse records and other information, timely and accurate transmission of medical insurance information system through the use of medical insurance fund data to the medical insurance administrative department report. Supervision and management of the use of medical insurance fund required information, information.
The fixed-point medical institutions should be in the unit's website, a prominent position to the community to disclose the price of medicine, medicine, cost, cost structure and other information, to accept social supervision.Article 13 public medical institutions shall implement the centralized purchasing and use of drugs and medical supplies system, through the centralized purchasing platform for the purchase and use of drugs and medical supplies. Other designated medical institutions are encouraged to purchase and use drugs and medical consumables through the centralized procurement platform.
Article 14 participants should hold their own medical insurance vouchers for medical treatment, purchase of medicines, and take the initiative to present for inspection. Participants have the right to request the designated medical institutions to truthfully produce bills and related information.
Participants should keep their medical insurance vouchers in a safe place to prevent others from using them under false pretenses. For special reasons, if you need to entrust someone else to buy drugs on behalf of others, you should provide proof of identity of the principal and the trustee. Participants should enjoy the medical insurance benefits in accordance with the provisions, and shall not be duplicated. Participants have the right to request the medical insurance organization to provide medical insurance consulting services, the use of medical insurance fund to propose improvements. Participants shall not use the opportunity of enjoying medical insurance benefits to resell medicines, accept the return of cash or in kind, or obtain other illegal benefits.Article 15 The medical insurance fund is earmarked for specific purposes, and no organization or individual may misappropriate or misappropriate it.
Chapter III Supervision and Management
Article 16 Bijie medical insurance fund shall establish a risk assessment mechanism, the medical insurance fund for the whole process of risk identification, through the identification of risks and management and disposal of risk, to ensure that the fund is safe and stable.
Article 17 city, county (autonomous counties, cities, districts) medical insurance administrative department is responsible for the administrative region of medical insurance administrative law enforcement work.
The use of medical insurance funds across counties (autonomous counties, cities and districts), the municipal medical insurance administrative department designated by the administrative department of medical insurance inspection.Article 18 The medical insurance administrative department of the medical insurance fund risk assessment, report complaint clues, medical insurance data monitoring, the higher departments referred to the news media exposure, medical insurance agencies and other departments to transfer the clues, to determine the focus of the inspection, organize and carry out special inspections.
Article 19 The administrative departments of medical insurance, together with public security, finance, health, market supervision and other departments to establish a joint law enforcement mechanism, carry out joint inspections, and implement joint disciplinary measures in accordance with the law.
Article 20 The medical insurance administrative department according to need, can hire qualified accounting firms, information technology services, commercial insurance institutions and other third-party organizations and professionals to assist in carrying out inspections.
Article 21 The administrative department of medical insurance shall regularly publicize the results of the supervision and inspection of the use of the medical insurance fund through the official website, microblogging public number or the news media to the public, and strengthen the exposure of cases of illegal use of the medical insurance fund, and accept the supervision of the community.
Article 22 municipalities, counties (autonomous counties, cities, districts) in accordance with the relevant provisions of the state and provincial medical insurance administrative departments to establish designated medical institutions, personnel and other credit management system, according to the credit rating classification supervision and management of the results of the day-to-day supervision and inspection results of the results of the administrative penalties, etc., into the national credit information **** enjoyment platform and other relevant information publicity system, the daily supervision and inspection results of the results of the administrative penalty into the national credit information **** enjoyment platform and other relevant information publicity system, and to strengthen the supervision of the medical insurance fund. Relevant information disclosure system, in accordance with the law, the implementation of credit incentives and penalties for breach of trust.
Article 23 The medical insurance agency shall, in accordance with the investigation and handling of cases by the administrative department of medical insurance, take appropriate measures in a timely manner in accordance with the service agreement. The medical insurance agency in the medical insurance services found in the administrative clues of violations of law, shall promptly report to the administrative department of medical insurance.
Chapter IV Accountability
Article 24 medical insurance agencies have the following behaviors, by the administrative department of medical insurance in accordance with the "supervision and management of the use of medical insurance fund regulations" shall be dealt with:
(a) failure to establish and improve the business, financial, safety and risk management system; (2) Failure to fulfill the management of service agreements, cost monitoring, fund disbursement, treatment review and payment and other duties; (3) Failure to regularly disclose to the community the income, expenditure and other balances of the medical insurance fund; (4) By means of forging, altering, concealing, altering, destroying medical documents, medical certificates, accounting vouchers, electronic information and other relevant information, or fictitious medical services. (d) Fraudulently obtaining expenditure from the medical insurance fund by falsifying, altering, or destroying medical documents, medical certificates, accounting vouchers, electronic information and other relevant information, or by fictionalizing medical services; (e) Other violations of the law that result in losses to the medical insurance fund.Article 25 fixed-point medical institutions have the following behaviors, by the medical insurance administrative department in accordance with the "Regulations on the Supervision and Management of the Use of Medical Insurance Fund" shall be dealt with; violation of other laws and administrative regulations, by the competent authorities shall be dealt with according to the law:
(a) decomposition of the hospitalization, hospitalization of the hanging beds; (b) violation of diagnostic and therapeutic norms of excessive diagnosis and treatment, excessive diagnosis and treatment, excessive treatment, excessive treatment, excessive treatment, excessive treatment, overdose, overdose, overdose, overdose and overdose, overdose and overdose. Diagnostic and therapeutic norms of over-diagnosis and treatment, excessive inspection, decomposition of prescriptions, over-prescription, repeat prescriptions, or provide other unnecessary medical services; (3) duplication of charges, over-standard charges, decomposition of charges; (4) collusion of medicines, medical consumables, diagnostic and treatment items and service facilities; (5) for the participants in the use of the opportunity to enjoy the benefits of the medical insurance scheme for the resale of drugs, accepting the return of cash, in kind, or obtain a refund of the medicines. (v) Facilitating participants to take advantage of the opportunity to enjoy medical insurance benefits to resell medicines, accept the return of cash, in kind, or obtain other illegal benefits; (vi) Incorporating into the medical insurance fund settlement of medical expenses that do not fall within the scope of the medical insurance fund; (vii) Inducing or assisting others to seek medical treatment under false names or falsely purchasing medicines, providing false certificates, or colluding with others to falsely invoice the expenses; (viii) Falsification, alteration, concealment, alteration, destruction of medical documents, medical certificates, medical certificates, medical certificates, medical certificates, and other medical certificates. (h) falsification, alteration, concealment, alteration, destruction of medical documents, medical certificates, accounting vouchers, electronic information and other relevant information; (ix) fictitious medical services; (j) for non-designated medical institutions to provide medical insurance settlement; (k) designated medical institutions in violation of the provisions of Articles 10, 11 and 12 of the Measures; (xii) other violations of laws and regulations resulting in losses of the medical insurance fund.Article 26 Individuals who commit any of the following acts shall be dealt with by the administrative department of medical insurance in accordance with the relevant provisions of the Regulations on the Supervision and Management of the Use of the Medical Insurance Fund:
(a) handing over one's own medical insurance voucher to another person for use under false pretenses; (b) duplicating the enjoyment of medical insurance benefits; (c) taking advantage of the opportunity to enjoy the medical insurance benefits to resell them; (d) using the opportunity to enjoy the medical insurance benefits to resell them; (e) using the opportunity to sell them to other persons to obtain the medical insurance benefits. (c) Using the opportunity of enjoying medical insurance benefits to resell medicines, accepting the return of cash or in-kind goods, or obtaining other unlawful benefits; (d) Other illegal and illicit behaviors that cause losses to the medical insurance fund.Article 27 The fixed-point medical institutions in violation of the service agreement, the medical insurance agency in accordance with the fixed-point service agreement can take the following ways to deal with:
(a) interviews with the legal representative of the institution, the main person in charge of the medical institution or the person who is actually controlling it; (b) suspension or not to pay the medical insurance fees; (c) recovery of the illegal medical insurance has been paid; (d) other illegal acts that cause losses to the medical insurance fund. Recovering paid medical insurance fees in violation of the law; (d) Suspending medical services involving the use of the medical insurance fund by the responsible personnel or their departments; (e) Requiring the designated medical institution to pay liquidated damages; (f) Suspending or terminating the service agreement.Article 28 Medical insurance and other administrative departments, medical insurance agencies, designated medical institutions and their staff accepting bribes or obtaining illegal income, in accordance with the "Regulations on Supervision and Management of the Use of the Medical Insurance Fund," the relevant provisions of the law; violation of other laws and administrative regulations, the competent authorities shall be dealt with according to law.
Article 29 Medical security and other administrative departments in the supervision and management of the use of medical insurance fund abuse of power, dereliction of duty, favoritism and malpractice, in accordance with the "supervision and management of the use of medical insurance fund regulations," the relevant provisions of the treatment.
Article 30 Violation of the provisions of these measures, misappropriation, misappropriation of medical insurance fund, by the medical insurance, finance and other administrative departments in accordance with the "Chinese People's Republic of China *** and the State Social Insurance Law," "supervision and management of the use of medical insurance fund regulations" and other relevant laws and regulations.
Article 31 In the process of investigating and dealing with violations of law, the administrative departments of medical insurance, health, market supervision, finance and other supervision and management departments of the medical insurance fund shall, in accordance with the law, transfer the facts of violation to the relevant departments if the facts of violation need to be dealt with by the public security authorities and other competent departments.
Chapter V Supplement
Article 32 Bijie City, urban workers' health insurance subsidies for large medical expenses, civil servants medical subsidies and other supervision and management of the use of medical insurance funds, with reference to the implementation of these measures.
Bijie City, urban and rural residents of the use of funds for major medical insurance in accordance with the relevant provisions of the State, the administrative department of medical insurance shall strengthen supervision and management.Article 33 These Measures shall come into force on the date of publication, the state or provincial supervision and management of the use of medical insurance fund has new provisions, from its provisions.