加强医保基金常态化监管

Strengthen the regular regulation of medical insurance funds.

近日，今年的医保基金飞行检查工作全面启动，飞检工作组已分赴地方，落实监管监督责任。医保基金是人民群众的“看病钱”“救命钱”，要进一步加强医保基金监管，时刻不能松懈。

In recent days, this year's medical insurance fund flight inspection work has been fully launched, and the flight inspection teams have been dispatched to local areas to ensure the implementation of regulatory and supervisory responsibilities. The medical insurance fund is the "medical expenses" and "life-saving money" for the people. It is necessary to further strengthen the supervision of the medical insurance fund and never slacken.

医保基金的安全运行，基金使用效率的提高，是减轻群众看病就医负担的重要基础。因此，相关主管部门始终将加强医保基金监管、维护基金安全作为医疗保障首要任务，持续开展专项整治，严厉打击各种违规违法使用医保基金的行为。近年来，通过飞行检查、专项整治和日常监管相结合，医保基金监管的高压态势已初步形成，监管威力不断显现，长效机制逐渐健全。国家医保局数据显示，2018年至2022年，对违法违规的医药机构处理154.3万家次，追回医保基金771.3亿元，曝光典型案例24.5万件。

The safe operation of the medical insurance fund and the improvement of fund utilization efficiency are important foundations for reducing the burden of medical expenses for the people. Therefore, the relevant authorities have always regarded strengthening the supervision of the medical insurance fund and maintaining fund security as the primary task of medical security. They have continuously carried out special rectification and cracked down severely on various illegal and irregular uses of the medical insurance fund. In recent years, through a combination of flight inspections, special rectification, and daily supervision, a high-pressure situation in the supervision of the medical insurance fund has been initially formed, and the regulatory power has been continuously demonstrated, with a gradually improved long-term mechanism. According to data from the National Medical Insurance Bureau, from 2018 to 2022, 1.543 million illegal and irregular medical institutions were dealt with, 77.13 billion yuan of medical insurance funds were recovered, and 245,000 typical cases were exposed.

尽管“明目张胆”的骗保行为有所遏制，但“跑冒滴漏”等老问题尚未有效根治，骗保手段更趋隐蔽。据国家医保局发布的2022年度医保基金飞行检查情况公告显示，在飞检组抽查的48家定点医疗机构中，都存在重复收费、超标准收费、分解项目收费问题。将不属于医保基金支付范围的医药费用纳入医保基金结算，违反诊疗规范过度诊疗、过度检查、超量开药等问题也依然存在。这说明，目前医保基金监管形势依然严峻复杂，亟须建立健全常态化监管的制度和方法，坚决守住基金的安全底线。

Although "blatant" fraudulent behaviors have been curbed to some extent, persistent issues like "running, faking, and leaking" have not been effectively eradicated, and fraudulent methods have become more concealed. According to the announcement on the flight inspection of the medical insurance fund in 2022, released by the National Medical Insurance Bureau, out of the 48 designated medical institutions randomly inspected by the inspection team, issues such as duplicate charges, charges exceeding standards, and decomposition of project charges were found in all of them. The inclusion of medical expenses that do not fall within the scope of medical insurance fund payment, excessive diagnosis and treatment, excessive examinations, and excessive medication, all violate medical norms. This indicates that the current situation of medical insurance fund supervision remains severe and complex, and it is urgent to establish and improve the system and methods of normalized supervision, firmly guarding the safety bottom line of the fund.

今年以来，《医疗保障基金飞行检查管理暂行办法》《2023年医保领域打击欺诈骗保专项整治工作方案》等多项相关举措出台，进一步加强医保基金监管，守住医保基金安全底线。今年5月，国务院办公厅印发《关于加强医疗保障基金使用常态化监管的实施意见》指出，加强医保基金使用常态化监管，对保障医保基金安全运行、提高基金使用效率、规范医疗服务行为、减轻群众看病就医负担具有重要意义。这些都充分体现了国家对打击医保基金违法违规行为、维护医保基金安全稳定运行的坚定决心。

Since this year, a number of related measures have been introduced, such as the interim measures for the Administration of unannounced Inspection of Medical Security funds, and the Special rectification work Plan for cracking down on fraud and insurance fraud in the field of Medical Insurance in 2023, to further strengthen the supervision of medical insurance funds and keep the safety bottom line of medical insurance funds. In May this year, the General Office of the State Council issued the ''Implementation Opinions on Strengthening the Normalized Supervision of the Use of Medical Insurance Funds'' and pointed out that strengthening the normalized supervision of the use of medical insurance funds will ensure the safe operation of medical insurance funds, improve the efficiency of funds' use, standardize medical service behavior, and reduce the burden of medical treatment for the masses . All these fully reflect the country's firm determination to crack down on illegal activities of medical insurance funds and maintain the safe and stable operation of medical insurance funds.

积极推行以远程监管、移动监管、预警防控为特征的非现场监管模式，通过事前提醒、事中预警、事后审核智能监管系统，让基金监管关口前移……目前，各级医保基金监管部门也正在进一步加大医保基金监管执法力度，切实落实各方监管责任，加强基金监管能力建设，综合运用多种监管方式，不断完善长效监管机制，加快构建权责明晰、严密有力、安全规范、法治高效的医保基金使用常态化监管体系。同时，以零容忍态度严厉打击欺诈骗保、套保和挪用贪占医保基金的违法行为，坚决守住医保基金安全底线，实现好、维护好、发展好最广大人民根本利益。

Actively promote the off-site supervision mode characterized by remote supervision, mobile supervision, early warning and prevention, and advance the focus of fund supervision through the intelligent supervision system of pre-warning, early warning and post-audit ...... At present, the supervision departments of medical insurance funds at all levels are also further strengthening the supervision and law enforcement of medical insurance funds, effectively implementing the supervision responsibilities of all parties, strengthening the construction of fund supervision capacity, comprehensively using a variety of supervision methods, and constantly improving the long-term supervision mechanism, accelerate the construction of a regular regulatory system for the use of health insurance funds with clear rights and responsibilities, strict and powerful, safe norms and efficient rule of law. At the same time, we will severely crack down on illegal acts of fraud, insurance, and embezzlement of medical insurance funds with a zero tolerance attitude, resolutely hold the bottom line of the safety of medical insurance funds, and realize, maintain, and develop the fundamental interests of the overwhelming majority of the people.

医保基金稳定运行关乎每个参保人的权益，监管部门要持续发力，全社会也要形成合力，继续保持打击医保欺诈骗保的高压态势，出重拳、用实招、求实效，更加高效、精准地保障人民群众的基本医药需求，共同守好老百姓的“救命钱”。

The stable operation of the medical insurance fund is related to the rights of each insured person. The regulatory authorities must continue to make efforts, and the whole society must also form a joint force to continue to maintain the high-pressure situation of combating medical insurance fraud and insurance fraud, and take strong measures, use practical means and pursue practical results. Efficiently and accurately guarantee the basic medical needs of the people, and jointly guard masses' medical insurance funds.