Home >Medical Guide > Outpatient Guide

Medical Security Fund use supervision and management regulations

 Hits: 3260 Time: 2021-04-26

Medical insurance fund use supervision and management regulations

Chapter I General principles

   Article 1 In order to strengthen supervision and management of the use of medical insurance funds, to protect the safety of the fund, to promote the effective use of the fund, to protect the legitimate rights and interests of citizens in medical insurance, according to the "Social Insurance Law of the People's Republic of China" and other relevant laws and regulations, to formulate these regulations.

   Article 2 These regulations apply to the People's Republic of China basic medical insurance (including maternity insurance) funds, medical assistance funds and other medical security funds and its supervision and management.

  Article 3 The use of medical insurance funds adhere to the people's health as the center, the level of protection and the level of economic and social development to adapt to follow the principles of lawful, safe, open and convenient for the people.

  Article 4 Supervision and management of the use of medical insurance funds to implement government supervision, social supervision, industry self-discipline and personal trustworthiness.

  Article 5 Above the county level people's government shall strengthen the supervision and management of the use of medical security funds leadership, establish and improve the use of medical security funds supervision and management mechanism and fund supervision and management of law enforcement system, strengthen the use of medical security funds supervision and management capacity building, for the use of medical security funds supervision and management work to provide security.

  Article 6 The State Council administrative department of medical security in charge of the national medical security fund use supervision and management work. Other relevant departments of the State Council in their respective areas of responsibility for the supervision and management of the use of medical insurance funds.

Local people's governments at or above the county level medical security administrative department is responsible for the administrative region of the medical insurance fund use supervision and management work. Local people's governments at or above the county level other relevant departments within their respective areas of responsibility is responsible for the supervision and management of the use of medical insurance funds.

  Article 7 The state encourages and supports the news media to carry out medical security laws, regulations and medical security knowledge of public welfare publicity, and the use of medical security funds to monitor public opinion. Publicity about medical security should be true and fair.

  People's governments at or above the county level and their medical security and other administrative departments should be through written consultation, held seminars and other ways to listen to the deputies of the National People's Congress, CPPCC members, representatives of the insured and other views on the use of medical security funds, open channels of social supervision, encourage and support the participation of all sectors of society in the supervision of the use of medical security funds.

  Medical institutions, pharmaceutical units (hereinafter collectively referred to as medical institutions) and other units and medical and health industry associations should strengthen industry self-discipline, regulate the behavior of pharmaceutical services, promote industry norms and self-restraint, guide the use of medical insurance funds in accordance with the law, reasonable.

Chapter II Fund use

   Article 8 The use of medical insurance funds should be in line with the scope of payment of the state regulations.

  The scope of payment of the medical insurance fund by the State Council medical insurance administrative department in accordance with the law to organize the development. Provinces, autonomous regions, municipalities directly under the Central People's Government in accordance with the state's authority and procedures, supplement the development of the administrative region of the medical insurance fund to pay the specific items and standards, and reported to the State Council administrative department of medical security for the record.

  Article 9 The state to establish and improve the national unified medical insurance management system, to provide standardized and standardized medical insurance services, to achieve full coverage of the province, city, county, township (street), village (community).

  Article 10 Medical security agencies should establish and improve the business, financial, security and risk management system, good service agreement management, cost monitoring, fund disbursement, treatment review and payment, and regularly disclose to the community the income, expenditure, balance of the medical security fund, etc., to accept social supervision.

  Article 11 Medical security agencies shall establish collective bargaining mechanism with the designated medical institutions, a reasonable determination of the designated medical institutions of the medical security fund budget amount and allocation time frame, and according to the protection of public health needs and management services, and the designated medical institutions to negotiate a service agreement, regulate the behavior of medical services, clear violations of the service agreement and its responsibility.

  Medical security agencies should promptly announce to the community the list of designated medical institutions that have signed service agreements.

  Medical insurance administrative departments shall strengthen the supervision of the conclusion of service agreements, performance and other circumstances.

  Article 12 The medical insurance agencies should be in accordance with the service agreement, timely settlement and disbursement of medical insurance funds.

  Designated medical institutions shall provide medical services in accordance with the provisions, improve the quality of services, the reasonable use of medical insurance funds, to protect the health rights and interests of citizens.

  Article 13 The designated medical institutions in violation of the service agreement, the medical security agencies can urge them to fulfill the service agreement, in accordance with the service agreement to suspend or not to allocate costs, recover the costs of violations, suspend the relevant responsible personnel or departments involved in the use of medical insurance funds medical services, until the termination of the service agreement; designated medical institutions and their relevant responsible personnel have the right to make statements, arguments.

  Medical insurance agencies violate the service agreement, the designated medical institutions have the right to request correction or request the medical insurance administrative departments to coordinate the processing, supervise the rectification, but also can apply for administrative reconsideration or bring an administrative lawsuit.

  Article 14 The designated medical institutions shall establish an internal management system for the use of medical insurance funds, by specialized agencies or personnel responsible for the use of medical insurance funds management, the establishment of a sound assessment and evaluation system.

  The designated medical institutions shall organize training on medical insurance fund-related systems and policies, and regularly check the use of medical insurance funds in the unit, and timely correction of the use of medical insurance funds is not standard behavior.

  Article 15 The designated medical institutions and their staff shall implement the management of real-name medical care and drug purchase, verification of medical insurance credentials of the participants, in accordance with the norms of medical treatment to provide reasonable and necessary medical services, to the participants truthfully issued cost documents and related information, shall not be decomposed hospitalization, hanging bed hospitalization, shall not violate the norms of medical treatment, excessive diagnosis and treatment, excessive examination, decomposition of prescriptions, over-prescription, repeat prescriptions, shall not repeat charges, over-standard charges, decomposition of project charges, shall not exchange drugs, medical supplies, treatment items and service facilities, shall not induce, assist others to impersonate or false medical treatment, drug purchase.

  Designated medical institutions shall ensure that the medical insurance fund to pay for the costs of the prescribed scope of payment; except for emergencies, rescue and other special circumstances, the provision of medical services outside the scope of payment of the medical insurance fund, should be agreed by the participants or their close relatives, guardians.

  Article 16 Designated medical institutions shall keep financial accounts, accounting vouchers, prescriptions, medical records, treatment and examination records, cost details, drugs and medical supplies in and out of the warehouse records and other information in accordance with the regulations, timely and accurate transmission of data related to the use of medical insurance funds through the medical security information system, to the medical security administrative departments to report the information required for the use of medical insurance funds supervision and management, to the public medical costs, cost structure and other information, and accept social supervision.

  Article 17 The insured shall hold their own medical insurance vouchers for medical treatment, drug purchases, and take the initiative to produce for inspection. The insured have the right to request the designated medical institutions to truthfully issue cost documents and related information.

  The insured person should keep his or her medical insurance certificate properly to prevent others from using it under false names. If you need to entrust someone else to purchase medicine for you for special reasons, you should provide proof of identity of the entrustor and the entrustee.

  The insured shall enjoy medical insurance treatment in accordance with the provisions, and shall not be repeatedly enjoyed.

  The insured person has the right to request the medical insurance agency to provide medical insurance consulting services and make suggestions for improvement in the use of the medical insurance fund.

  Article 18 In the use of medical security funds, medical security and other administrative departments, medical security agencies, designated medical institutions and their staff shall not accept bribes or obtain other illegal income.

  Article 19 The participants shall not use their access to medical security treatment to resell drugs, accept the return of cash, in kind or obtain other illegal benefits.

  Designated medical institutions shall not use the opportunity for the participants to enjoy medical insurance treatment to resell drugs, accept the return of cash, in kind or to obtain other illegal benefits to facilitate.

  Article 20 Medical insurance agencies, designated medical institutions and other units and their staff and participants and other personnel shall not forge, alter, conceal, alter, destroy medical documents, medical certificates, accounting vouchers, electronic information and other relevant information, or fictitious medical services, etc., to fraudulently obtain medical insurance funds.

  Article 21 The medical insurance fund for the exclusive use of any organization or individual shall not be appropriated or misappropriated.

Chapter III Supervision and management

  Article 22 The medical security, health, Chinese medicine, market supervision and management, finance, audit, public security and other departments should be divided into collaboration, cooperation, the establishment of communication and coordination, case referral and other mechanisms to do a good job in the supervision and management of the use of medical security funds.

  Medical security administrative departments should strengthen the supervision of medical service practices and medical expenses included in the scope of payment of medical insurance funds, standardize the medical insurance business, and investigate and deal with the illegal use of medical insurance funds.

  Article 23 The administrative department of medical insurance of the State Council is responsible for formulating the management of service agreements, standardizing, simplifying and optimizing the procedures for the application, professional evaluation and negotiation of medical institutions' fixed points, and making and regularly revising the model service agreements.

  The administrative department of medical security of the State Council to develop service agreements management methods, should listen to the relevant departments, medical institutions, industry associations, the public, experts and other aspects of the views.

  Article 24 The administrative department of medical security shall strengthen the exchange and sharing of information with relevant departments, innovative ways of supervision and management, promote the use of information technology, the establishment of a national unified, efficient, compatible, convenient and secure medical security information system, the implementation of real-time dynamic intelligent monitoring of big data, and strengthen the use of shared data management throughout the process to ensure the security of shared data.

  Article 25 The administrative department of medical security shall, based on the risk assessment of medical security funds, reports and complaints clues, medical security data monitoring and other factors, to determine the focus of inspection and organize special inspections.

  Article 26 The administrative department of medical security can work with health, Chinese medicine, market supervision and management, finance, public security and other departments to carry out joint inspections.

  Cross-regional medical security fund use behavior, the common higher level of medical security administrative department designated by the medical security administrative department inspection.

  Article 27 The medical security administrative departments to implement supervision and inspection, you can take the following measures.

  (A) to enter the scene to inspect.

  (B) to question the relevant personnel.

  (C) to require the subject of the inspection to provide documents and information related to the matter under inspection, and to make explanations and clarifications

  (D) to take records, audio, video, photography or reproduction and other means to collect relevant information and data.

  (E) to be transferred, concealed or lost information, etc. to be sealed.

  (F) to engage qualified accounting firms and other third-party institutions and professionals to assist in the inspection.

(G) other measures provided by laws and regulations.  

Article 28 The administrative department of medical insurance can be entrusted to meet the statutory conditions of the organization to carry out medical insurance administrative law enforcement work.

  Article 29 supervision and inspection of the use of medical insurance funds, supervision and inspection personnel shall not be less than two people, and shall present law enforcement documents.

  Medical insurance administrative departments to carry out supervision and inspection, the object of inspection shall cooperate, truthfully provide relevant information and information, shall not refuse, obstruct the inspection or misrepresentation, concealment.

  Article 30 Designated medical institutions suspected of fraudulent medical insurance fund expenditures, during the investigation, the medical security administrative departments can take measures to increase the frequency of supervision and inspection, strengthen cost monitoring, etc., to prevent the expansion of losses. If the designated medical institutions refuse to cooperate with the investigation, approved by the main person in charge of the administrative department of medical security, the administrative department of medical security can request the medical security agencies to suspend the settlement of medical security funds. After investigation, is a fraudulent medical insurance fund expenditures, in accordance with the provisions of Article 40 of these regulations; is not a fraudulent medical insurance fund expenditures, in accordance with the provisions of the settlement.

Participant suspected of fraudulent medical insurance fund expenditures and refused to cooperate with the investigation, the medical security administration can request the medical insurance agencies to suspend the settlement of medical expenses network. Suspension of the network settlement of medical expenses incurred during the period, the full amount of the participant advance. After investigation, is a fraudulent medical insurance fund expenditures, in accordance with the provisions of Article 41 of these regulations; is not a fraudulent medical insurance fund expenditures, in accordance with the provisions of the settlement.  

  Article 31 The administrative department of medical security for violations of these regulations to make administrative penalties or administrative treatment before the decision, shall listen to the parties' statements, pleadings; to make administrative penalties or administrative treatment decisions, the parties shall be informed of the right to apply for administrative reconsideration or bring administrative proceedings.

  Article 32 The medical security and other administrative departments, medical security agencies, accounting firms and other institutions and their staff, shall not work to obtain, know the subject of the investigation data or related information for purposes other than supervision and management of the use of medical security funds, shall not disclose, alter, destroy, illegally provide others with the personal information and commercial secrets.

  Article 33 The State Council administrative department of medical security shall establish a designated medical institutions, personnel and other credit management system, according to the credit evaluation level of hierarchical classification of supervision and management, the results of daily supervision and inspection, administrative penalties and other information into the national credit information sharing platform and other relevant information disclosure system, in accordance with relevant state regulations to implement disciplinary action.

  Article 34 The administrative department of medical security shall regularly publish the results of supervision and inspection of the use of medical security funds to the community, and increase the exposure of cases of illegal use of medical security funds to accept social supervision.

  Article 35 Any organization and individual has the right to infringe on the medical security fund violations of the law, complaints.

Medical insurance administrative departments should be open channels for reporting complaints, timely handling of complaints, and the confidentiality of information about the whistleblower. The report found to be true, in accordance with relevant state regulations to give the whistleblower rewards.

Chapter IV Legal Liability

  Article 36 The administrative department of medical security shall order the medical security agency to make corrections in any of the following cases, and shall impose sanctions on the directly responsible supervisors and other personnel directly responsible in accordance with law.

  (A) failure to establish a sound operational, financial, security and risk management system.

  (B) failure to perform the service agreement management, cost monitoring, fund disbursement, treatment review and payment and other duties.

  (C) not regularly disclose to the public the income, expenditure and balance of the medical insurance fund.

  Article 37 The medical insurance agencies through forgery, forgery, concealment, alteration, destruction of medical documents, medical certificates, accounting documents, electronic information and other relevant information or fictitious medical services, fraudulent medical insurance fund expenditures, the medical insurance administrative department ordered to return, impose a fine of more than two times the amount of fraudulent 5 times, the person directly responsible for the supervisor and other directly responsible personnel In accordance with the law to give disciplinary action.

  Article 38 The designated medical institutions have one of the following circumstances, the administrative department of medical security shall order correction, and may interview the person in charge; causing losses to the medical security fund, ordered to return, impose a fine of more than 1 times the amount of losses caused by 2 times; refusal to correct or cause serious consequences, ordered the designated medical institutions to suspend the relevant responsible departments for more than 6 months and less than 1 year involving the use of medical security funds Medical services; violation of other laws and administrative regulations, by the relevant competent departments in accordance with the law to deal with.

  (a) decomposition of hospitalization, hanging bed hospitalization.

  (b) excessive diagnosis and treatment, excessive examination, decomposition of prescriptions, over-prescription, repeat prescription or provide other unnecessary pharmaceutical services in violation of treatment norms.

  (c) repeated charges, over-standard charges, decomposition project charges.

  (d) the exchange of drugs, medical supplies, treatment items and service facilities.

  (e) facilitate the use of the opportunity for participants to resell drugs, accept returns in cash or in kind or obtain other illegal benefits.

  (f) to include medical expenses that are not covered by the medical insurance fund in the settlement of the medical insurance fund.

  (g) other illegal acts that cause losses to the medical insurance fund.

  Article 39 The designated medical institutions have one of the following circumstances, the medical security administrative department shall order correction, and may interview the person in charge; refuses to correct, a fine of 10,000 yuan or less than 50,000 yuan; violation of other laws and administrative regulations, by the relevant competent departments in accordance with law.

  (a) Failure to establish an internal management system for the use of medical insurance funds, or no specialized agencies or personnel responsible for the use of medical insurance funds management.

  (b) Failure to maintain financial accounts, accounting vouchers, prescriptions, medical records, treatment and examination records, cost details, drugs and medical supplies in and out of the warehouse records and other information in accordance with the provisions.

  (c) Failure to transmit data related to the use of the medical insurance fund through the medical insurance information system in accordance with the regulations.

  (d) Failure to report to the medical insurance administrative department in accordance with the provisions of the information required for the supervision and management of the use of medical insurance funds.

  (e) Failure to disclose medical costs, cost structure and other information to the community in accordance with the regulations.

  (f) Except for emergency medical treatment, rescue and other special circumstances, without the consent of the insured person or his close relatives or guardians to provide medical services outside the scope of payment of the medical insurance fund.

  (g) Refuse medical security and other administrative departments to supervise and inspect or provide false information.

  Article 40 The designated medical institutions through the following ways to fraudulently obtain medical insurance fund expenditures, the medical security administrative departments ordered to return, impose a fine of more than two times the amount of fraudulent 5 times; ordered the designated medical institutions to suspend the relevant responsible departments for more than 6 months and less than 1 year involving medical services for the use of medical insurance funds, until the medical security agencies to terminate the service agreement; practice qualifications, by the relevant The competent authorities shall revoke the license to practice.

  (a) induce, assist others to impersonate or false medical treatment, purchase drugs, provide false supporting documents, or collude with others to falsely bill expenses.

  (b) forging, altering, concealing, altering, destroying medical documents, medical certificates, accounting vouchers, electronic information and other relevant information

  (c) fictitious medical services.

  (d) other fraudulent medical insurance fund expenditures.

  Designated medical institutions for the purpose of fraudulent medical insurance funds, the implementation of one of the acts specified in Article 38 of these regulations, resulting in losses to the medical insurance fund, in accordance with the provisions of this article.

  Article 41 The individual has one of the following circumstances, the administrative department of medical security shall order correction; cause losses to the medical security fund, order the return; belong to the participants, suspend their medical expenses network settlement for 3 months to 12 months.

  (a) the medical insurance vouchers of their own to others to use under false pretenses.

  (b) repeatedly enjoy the medical security treatment.

  (c) use the opportunity to enjoy medical insurance treatment to resell drugs, accept the return of cash, in kind or obtain other illegal benefits.

  Individuals for the purpose of fraudulent medical insurance funds, the implementation of one of the acts specified in the preceding paragraph, resulting in the loss of medical insurance funds; or the use of another person's medical insurance voucher fraudulent name for medical treatment, drug purchase; or through forgery, alteration, concealment, alteration, destruction of medical documents, medical certificates, accounting vouchers, electronic information and other relevant information or fictitious medical services, etc., fraudulent medical insurance fund expenditures, in addition to In accordance with the provisions of the preceding paragraph, shall also be dealt with by the administrative department of medical security at more than two times the amount of fraudulent 5 times the fine.

  Article 42 The administrative departments of medical insurance, medical insurance agencies, designated medical institutions and their staff accept bribes or obtain other illegal income, confiscate the illegal income, the responsible personnel shall be punished according to law; violation of other laws and administrative regulations, by the competent departments in accordance with law.

  Article 43 The designated medical institutions in violation of the provisions of these regulations, resulting in significant losses to the medical insurance fund or other serious adverse social impact, its legal representative or the main person in charge of the five-year ban on the management activities of designated medical institutions, the relevant departments shall be punished.

  Article 44 Violation of the provisions of these regulations, embezzlement, misappropriation of medical insurance funds, the medical security and other administrative departments shall order the recovery; illegal income, confiscate the illegal income; directly responsible for the competent personnel and other directly responsible personnel shall be punished according to law.

  Article 45 The return of funds returned to the original medical insurance fund financial account; fines, confiscated the illegal income shall be paid to the State Treasury.

  Article 46 The medical security and other administrative departments, medical security agencies, accounting firms and other institutions and their staff, leaking, tampering, destruction, illegal provision of personal information to others, commercial secrets, the directly responsible supervisors and other directly responsible personnel shall be punished according to law; violation of other laws and administrative regulations, the relevant competent departments in accordance with law.

  Article 47 The medical security and other administrative departments staff in the supervision and management of the use of medical security funds abuse of power, negligence, corruption, shall be punished according to law.

Article 48 Violation of the provisions of these Regulations, the relevant units or individuals caused damage, shall bear the responsibility for compensation.

Chapter V By-laws

  Article 49 The supervision and management of the use of medical insurance funds such as subsidies for large medical expenses of employees and medical benefits for civil servants shall be implemented with reference to these Regulations.

  Residents of the use of major medical insurance funds in accordance with relevant state regulations, the medical security administrative departments shall strengthen supervision.

  Article 50 These Regulations shall come into force on May 1, 2021.