The first medical insurance supervision regulations were issued to jointly manage and use the people's "life-saving money" well.

This is the 3039th article of Da Yi Xiao Hu

There are many users of medical insurance funds, the chain is long, there are many risk points, and the supervision is difficult. Fraud and insurance fraud continue to occur frequently, and the supervision situation has been relatively severe. The state attaches great importance to the supervision and management of the use of medical insurance funds. Since the establishment of the National Medical Insurance Administration, the supervision of medical insurance funds has made unprecedented progress. A large number of fraud and insurance fraud have been investigated and dealt with, and a high-pressure situation to combat fraud and insurance fraud has been initially formed. In 2020, the medical insurance and health departments, on the basis of comprehensive self-examination and self-correction, inspected more than 600,000 designated medical institutions. Including self-examination and inspection, a total of more than 400,000 designated medical institutions that violated laws, regulations and contracts were dealt with. In other words, more than half of the designated medical institutions have problems with the use of funds to varying degrees, and 22.31 billion yuan of medical insurance funds have been recovered.

The Opinions of the CPC Central Committee and the State Council on Deepening the Reform of the Medical Security System, issued in March 2020, proposed to formulate and improve relevant laws and regulations on the supervision of medical insurance funds, and standardize the supervision authority, procedures and punishment standards. The Guiding Opinions of the General Office of the State Council on Promoting the Reform of the Medical Security Fund Supervision System proposed to strengthen the rule of law and standardized protection of medical insurance fund supervision, and formulate the Regulations on the Supervision and Administration of the Use of Medical Security Funds and related supporting measures.

On February 19, 2021, the State Council promulgated the first administrative regulation of the national medical insurance system, the "Regulations on the Supervision and Administration of the Use of Medical Insurance Funds" (hereinafter referred to as the "Regulations"), which will come into effect on May 1, 2021. The "Regulations" have 5 chapters and 50 articles, including general provisions, fund use, supervision and administration, legal liability and supplementary provisions.

The general provisions and supplementary provisions of the Regulations clearly define the scope of application, the use of medical security funds such as basic medical insurance (including maternity insurance) funds and medical assistance funds within the territory of the People's Republic of China, and their supervision and management. The supervision and management of the use of medical security funds such as employee large medical expense subsidies and civil servant medical subsidies shall be implemented in accordance with these Regulations.

In addition, the general provisions also clarify the concept of social co-governance. First, the Regulations clarify that the supervision and management of medical security funds shall be implemented by combining government supervision, social supervision, industry self-discipline and personal trustworthiness; the state encourages and supports the news media to carry out public welfare publicity of medical security laws, regulations and medical security knowledge, and conduct public opinion supervision on the use of medical security funds. Second, it requires the people's governments at or above the county level and their administrative departments such as medical security to listen to the opinions of deputies to the National People's Congress, members of the Chinese People's Political Consultative Conference, representatives of insured persons, etc. on the use of medical security funds through written solicitation of opinions, holding seminars, etc.; unblock social supervision channels, encourage and support all aspects of society to participate in the supervision of the use of medical security funds. Third, medical institutions and other institutions should strengthen industry self-discipline, standardize medical service behaviors, promote industry norms and self-discipline, and guide the legal and reasonable use of medical security funds. Fourth, it clarifies that the results of the supervision and inspection of the use of medical security funds shall be announced to the public on a regular basis, increase the exposure of illegal cases of the use of medical security funds, accept social supervision, unblock reporting and complaint channels, and reward the whistleblower for reports that are verified to be true in accordance with relevant national regulations.

Chapter 2 of the Regulations on the Use of Funds clearly stipulates the behavioral norms for the four major entities of medical insurance administrative departments, medical insurance handling agencies, designated medical institutions, and insured persons. The responsibilities of these entities in the use of funds are clearly defined, and they perform their duties and regulate their behavior, so as to ensure the safe and effective use of funds.

01

Medical insurance administration department

The main responsibility is to clarify the rules and standards for the use of the fund and supervise their implementation. The Regulations require that the medical security administrative department shall formulate the payment scope and payment standards of the medical security fund, strengthen the supervision and management of medical service behaviors and medical expenses included in the medical insurance scope, and investigate and deal with illegal and irregular behaviors in the field of medical security in accordance with the law.

02

Medical insurance agency

The main responsibility is to improve the management system and enhance the service capabilities. The Regulations stipulate that medical insurance agencies should improve the unified management system across the country, provide standardized and regular management services, strengthen the construction of business, financial, safety and risk management systems, and do a good job in agreement management, cost monitoring, fund allocation, treatment review and payment and other related work. In accordance with the needs of protecting public health and management services, medical insurance agreements should be signed with designated medical institutions, medical service behaviors should be standardized, and behaviors that violate the agreement and their responsibilities should be clarified.

03

Designated medical institutions

It is also the most critical subject, which directly affects the vital interests of the insured and their experience of seeking medical treatment and purchasing medicine. The Regulations mainly stipulate from three levels. First, at the management level, designated institutions must strengthen internal management, keep materials and submit information in accordance with regulations. Secondly, at the level of general behavioral norms, designated institutions must abide by relevant behavioral norms and provide reasonable and necessary medical services. Thirdly, at the level of prohibiting fraud and insurance fraud, a red line is clearly drawn for designated institutions, prohibiting them from defrauding medical insurance funds by fictitious medical services, false medical treatment and purchase of medicines, and forging and altering relevant materials.

04

Insured Persons

The behavior of insured persons also directly affects the safety and benefits of the medical insurance fund. Therefore, the Regulations have made corresponding provisions, requiring insured persons to use their medical insurance certificates to seek medical treatment and purchase medicines, and enjoy medical insurance benefits in accordance with the regulations. They shall not use the opportunity of enjoying medical insurance benefits to resell medicines, accept cash or physical returns, or obtain other illegal benefits.

Chapter III of the Regulations on Fund Management strengthens the means of supervision and management of medical insurance funds. First, it is clear that a multi-form supervision and management system will be implemented, including special inspections and joint inspections. Second, it is clear that an intelligent monitoring system will be established, information exchange and sharing with relevant departments will be strengthened, a national unified, efficient, compatible, convenient and secure medical security information system will be established, and real-time dynamic intelligent monitoring of big data will be implemented. And strengthen the management of the entire process of shared data use to ensure the security of shared data. Third, it is clear that a credit management system for designated medical institutions and personnel will be established, and supervision and management will be carried out according to the classification and classification of credit evaluation registration, and penalties will be implemented in accordance with relevant national regulations.

What needs to be paid special attention to is that if the insured person is suspected of defrauding medical insurance fund expenditures and refuses to cooperate with the investigation, the medical insurance administrative department may require the medical insurance agency to suspend the online settlement of medical expenses. The medical expenses incurred during the suspension of online settlement shall be paid in full by the insured person.

From this, it can be seen that the implementation of the Regulations has further refined the procedures for standardizing medical insurance fund supervision.

Chapter 4 of the Regulations on Legal Liabilities has significantly increased the intensity of supervision and penalties. While further establishing and improving the supervision mechanism, the Regulations use a variety of punishment measures for different illegal entities, illegal behaviors, and illegal situations, set corresponding legal responsibilities, increase the intensity of punishment for illegal behaviors, make violators pay a greater price, and then guide and urge the users of medical insurance funds to better comply with the law. There are several specific aspects:

First, for medical insurance agencies, different violations are distinguished and regulations are issued to order them to correct the violations, order them to return the money, impose fines, and impose penalties on directly responsible supervisors and other directly responsible persons.

Second, for designated medical institutions, the different illegal acts are distinguished, and the regulations stipulate that they must be ordered to make corrections, interview the relevant persons in charge, order the return of money, impose fines, revoke the qualification to practice, restrict employment, and impose penalties. In particular, for insurance fraud, relatively severe penalties are set. In addition to the penalties such as ordering the return of money and revoking the qualification to practice, a fine of more than 2 times but less than 5 times the amount of money defrauded is also stipulated. In view of the characteristics of the agreement management of designated medical institutions, the regulations stipulate the suspension of medical services involving the use of funds and the period, as well as the termination of service agreements. It is particularly worth mentioning that compared with the Social Insurance Law, the Regulations have added seven new acts that cause losses to the medical insurance fund, such as the decomposition of hospitalization, hanging beds in hospital, excessive diagnosis and treatment in violation of diagnosis and treatment norms, excessive examinations, and substitution of drugs, into administrative penalties.

At the same time, in order to strengthen the management responsibility of the heads of designated medical institutions, the administrative "double punishment system" is introduced to implement "punishment to individuals". If a designated medical institution causes major losses to the fund or serious adverse social impact due to illegal acts, its legal representative or main person in charge will be restricted from working for 5 years.

Third, for individual illegal acts, it is stipulated that they shall be ordered to correct, return, and suspend their medical expenses online settlement for 3 to 12 months. For individuals who defraud insurance, they shall be fined more than 2 times but less than 5 times the amount of the defrauded money, just like designated medical institutions.

Fourth, regulations stipulate that those who embezzle or misappropriate medical insurance funds shall be ordered to recover the funds, confiscate the illegal gains, and impose penalties.

Fifth, corresponding legal responsibilities are stipulated for administrative staff of medical insurance and other departments who abuse their power, neglect their duties, or engage in malpractice for personal gain.

In addition, the Regulations also link criminal liability and other administrative liabilities for illegal acts with relevant laws and administrative regulations.

The promulgation and implementation of the Regulations marks a new journey for the legalization of medical insurance fund supervision, which has promoted the continuous enhancement of the efficiency of medical insurance fund supervision and is conducive to our standardization of the use of medical insurance funds. At the same time, it will enhance the main responsibility awareness of designated medical institutions and insured persons, improve the joint governance capacity of medical insurance funds in the whole society, and protect the health and safety of the people.

Author: Zheng Jun, a lawyer at Shanghai Boss & Yang Zhongjian Zhonghui Law Firm