The National Healthcare Security Administration (NHSA), National Health Commission, and National Medical Products Administration (NMPA) have jointly issued guidelines aimed at establishing a medical insurance payment eligibility management system for personnel at designated medical institutions. This initiative pertains to individuals at such institutions who are involved with the use of medical insurance funds.
Under the new framework, designated medical institutions will enter into service agreements with medical insurance agencies. Personnel involved with medical insurance funds at these institutions will be eligible for medical insurance payments and will be subject to medical insurance supervision. The personnel primarily fall into two categories: the first includes hospital-related personnel such as medical, nursing, and technical health professionals who offer services to insured individuals, as well as staff responsible for medical expense and insurance claim review. The second category encompasses the principal officers in charge of designated retail pharmacies, as indicated on the drug business license. A dynamic scoring system will be applied to monitor the conduct of relevant personnel.
In the event of any misconduct or irregularities, personnel will be assigned scores based on the severity of their actions. Minor offenses will result in 1-3 points, moderate offenses will lead to 4-6 points, more serious cases will be penalized with 7-9 points, and the most severe instances involving fraud and insurance fraud will be assigned 10-12 points. Should an individual accumulate 12 points within a calendar year, their eligibility for medical insurance payments will be revoked, and any medical insurance fees incurred during the termination period will not be reimbursed. If medical insurance payment eligibility is suspended or terminated at a designated medical institution, corresponding actions will also be implemented at other such institutions.- Flcube.com
