The National Healthcare Security Administration (NHSA) has released a set of regulations aimed at improving the management of Diagnosis Related Groups (DRG) and Diagnosis-Intervention Packet (DIP) payment methods under the multi-level medical security system of “1+3+N”. The document emphasizes the need for better coordination between payment methods and reforms in medical service pricing, volume-based procurement (VBP), National Reimbursement Drug List (NRDL) negotiations, commercial health insurance, fund supervision, and other areas. It also highlights the importance of real-time, direct, and synchronous settlements.
Unified Management and Information Platform
The regulations clarify that DRG/DIP payment methods will be included in the scope of agreement management. Handling agencies and designated medical institutions are required to sign medical security service agreements to define the rights and obligations of both parties. The government will accelerate the implementation of a unified national medical insurance information platform and build a full-process online management system. This includes standardizing the application of national medical insurance information business coding standards and ensuring data collection quality control and information security.
Local Implementation and Budget Management
All regions are required to determine local DRG subgroups and DIP disease catalogs in accordance with national DRG/DIP technical specifications and based on local conditions. They must also prepare annual fund expenditure budgets based on the principles of fixed income and expenditure, balanced income and expenditure, and slight surplus. A portion of the budget can be reserved for mid-year adjustments and reasonable compensation and sharing of overspending in annual liquidation. The document suggests exploring the incorporation of the medical insurance fund for inter-provincial hospitalization settlement into the budget management of medical treatment locations and establishing a prepayment system for medical insurance funds. Prepayments in eligible regions should be made around one month in advance, and a quality guarantee deposit (not exceeding 5%) should be reserved, to be disbursed in the annual settlement based on assessment and evaluation results.
Special Case Management
For cases with long hospitalization times, high medical expenses, consumption of new drugs and technologies, complex and critical illnesses, or multidisciplinary joint diagnosis and treatment that are not suitable for DRG/DIP payment, medical institutions can independently apply for special cases. These cases can implement project payment or adjust the payment standards. Special case declarations will be conducted online or offline, on a quarterly or monthly basis. The number of DRG special cases per case shall not exceed 5% of the total discharged DRG cases in the overall area, and the number of DIP special cases per case shall not exceed 5‰ of the total discharged DIP cases in the overall area.-Fineline Info & Tech
