The National Healthcare Security Administration (NHSA) has released a notification detailing planned measures to improve the smart monitoring and auditing of Basic Medical Insurance (BMI) funds. The initiative focuses on addressing disparities in the implementation of the national 1.0 version smart monitoring and auditing system and building upon the existing knowledge base and rules.
Timeline and Goals for Smart Monitoring Sub-Systems
The document mandates that smart monitoring sub-systems must be operational in all coordination areas by the end of 2023, with accurate data upload to the national BMI information platform. Full implementation is required in relation to standardizing service behavior in designated medical institutions. The connectivity between protocol processing and administrative supervision, as well as verification handling and administrative law enforcement, aims to establish a national smart monitoring “one network”.
Targeting a Standardized Smart Monitoring and Auditing System by 2025
By the end of 2025, the NHSA aims to have a standardized, scientific, and normalized smart monitoring and auditing system in place. The development and refinement of “two bases” for smart auditing, and anti-fraud big data smart monitoring and analysis, will be prioritized. Informatisation and digitization are set to fully empower medical insurance audit and fund supervision.
Adapting to Changes and Strengthening Oversight
Relevant entities are advised to adapt to the upcoming changes, reform outpatient mutual assistance guarantee mechanisms, and enhance the supervision of designated medical institutions. Strengthening the review and supervision of BMI funds under the DRG/DIP payment methods is also emphasized.
Focus on Medical Institutions’ Diagnosis and Treatment Behavior
The auditing and monitoring focus on medical institutions’ diagnosis and treatment behavior. Establishing a nationally unified, standardized, practical, and transparent auditing and monitoring system, with clear regulatory red lines, is seen as crucial. Extending smart monitoring to hospitals through information system integration is viewed as enabling a proactive role for the NHSA in preventing potential problems at their source.
Supervision and Intervention for Violations
For clear violations, it is necessary to strengthen supervision and intervention, aiming to achieve automatic interception of violations that can be rigidly constrained. For issues related to medical rationality, local healthcare security departments should consider the opinions and suggestions of medical institutions when demonstrating and applying rules. After the system detects suspicious issues, prompt feedback should be given to designated medical institutions, and a full appeals process for medical institutions should be established.-Fineline Info & Tech
