The Measures announced yesterday also include penalties for four other types of individual violations of health insurance regulations, including lending one's basic health insurance vouchers to others, or transferring diagnosis and treatment vouchers and settlement documents for a fee to settle basic health insurance expenses; making basic health insurance payments by repeating medical visits or forging, altering or changing medical histories, prescriptions, reimbursement vouchers and medical bills; selling vouchers issued by the basic health insurance system; and selling vouchers issued by the basic health insurance system to others to settle basic health insurance expenses. The same provisions apply to the sale of medicines covered by the basic health insurance, and to the settlement of basic health insurance costs in other ways that harm the health insurance fund.
The original Shanghai Urban Workers' Basic Medical Insurance Measures stipulated that if the number of outpatient emergency visits or medical expenses incurred by an insured person is significantly higher than normal, the insured person may be subjected to a change in the method of accounting and settlement of outpatient emergency medical expenses, i.e., from the original online "credit card" accounting and settlement of outpatient emergency medical expenses to a cash payment with a fixed amount of money, to a cash payment with a fixed amount of money, to a cash payment with a fixed amount of money. In other words, from the original online "swipe card" settlement of outpatient emergency medical expenses, it will be changed to cash settlement with the designated medical institutions, and then apply for reimbursement at the designated county medical insurance centers with the medical insurance and other relevant information. The implementation of this measure has played a positive role in maintaining the safety of the health insurance fund. However, the number of outpatient emergency visits or incurred medical costs significantly more than normal for a variety of reasons such as specific conditions.
So yesterday's announcement of the "Measures" stipulates that the measures taken to temporarily change the outpatient emergency basic health insurance cost billing and settlement of measures, the City Health Insurance Supervision and Inspection Office should notify the participants, and its medical situation in a timely manner for review. If no irregularities are found after the audit, it shall resume the booking and settlement of outpatient emergency basic medical insurance fees on the day when the audit and inspection are completed.
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Specified medical institutions, designated retail pharmacies violation of the penalty provisions
One of the following behaviors will be ordered to make corrections, to recover the medical insurance costs that have been paid by the medical insurance fund, and may be subject to a warning or a fine of 3,000 yuan or more than 100,000 yuan or less; if the circumstances are serious, you can also suspend its basic medical insurance settlement relationship for one to six months or cancel its qualification as a designated basic medical insurance center:
(1) failing to verify the basic medical insurance vouchers in accordance with the regulations, and settling the basic medical insurance fees for individuals who use the basic medical insurance vouchers to seek medical treatment or dispense medicines in violation of the regulations;
(2) adopting the methods of duplicated registration, duplicated or unindicated laboratory tests, inspections and treatments for insured persons, and decomposed or unindicated hospitalization to make false claims for (b) Using double registration or repeated or unqualified laboratory tests, examinations and treatments for the insured person, breaking down or hospitalizing the insured person without a qualification, fictitious medical services or providing unnecessary medical services, and settling basic medical insurance expenses;
(c) Violating the relevant provisions of the basic medical insurance and settling the basic medical insurance expenses for medical expenses incurred for diagnostic and therapeutic items and medical service facilities outside the scope of the medical insurance fund's payment or the scope of the agreed services;
(d) Violating the regulations on the scope of medication or variety of medication (d) violating the regulations on the scope of medicines to be used or the varieties of medicines to be used, dispensing medicines to the insured by overdosing, duplicating medicines, using medicines with special restrictions in violation of the regulations, or dispensing medicines to the insured by breaking down or changing the prescriptions to settle the basic medical insurance expenses;
(e) settling the basic medical insurance expenses by charging the insured by duplicating, breaking down, overcharging, or charging at its own standards
(6) not in accordance with the basic medical insurance payment ratio for basic medical insurance cost settlement;
(7) not in accordance with the provisions of Article 7 of the Measures to re-approve the qualification of the basic medical insurance fixed-point approval procedures, unauthorized implementation of the network for basic medical insurance cost settlement.
Specified medical institutions, designated retail pharmacies serious violations of the penalty provisions
One of the following acts will be ordered to correct, recover the medical costs already paid by the medical insurance fund, and may be subject to a warning or a fine of 30,000 yuan or more than 100,000 yuan; the circumstances of the seriousness of the situation, but also to suspend the basic medical insurance settlement relationship for one to six months or cancel the qualification of its basic medical insurance designated:
(1) unauthorized networking with non-designated medical institutions or retail pharmacies for basic medical insurance fee settlement;
(2) using forged or falsified medical history records, prescriptions, accounts, medical bills, uploaded data, etc., for basic medical insurance fee settlement;
(3) passing off non-pharmaceutical items such as daily necessities and health care supplements as drugs within the scope of medical insurance.
(c) Using daily necessities, health care supplements and other non-medicinal items as medicines within the scope of basic medical insurance to settle basic medical insurance expenses;
(d) Adopting other methods that harm the medical insurance fund to settle basic medical insurance expenses.