The National Healthcare Security Administration (NHSA), National Health Commission (NHC), along with two other bureaus, have jointly issued a notification to commence unannounced inspections of medical insurance funds for the period from January 1, 2022, to December 31, 2023. The inspections will concentrate on the utilization and management of medical insurance funds and the establishment and enforcement of related internal control systems.
Each province will select two cities for inspection: the provincial capital and a second city chosen at random, including another prefecture-level city within the province. The inspections will assess the allocation of medical insurance funds and resources and identify the list of designated medical institutions within the national unannounced inspection sampling scope. The unannounced inspection teams will randomly select or determine 2-3 designated medical institutions from each city included in the list. For municipalities directly under the central government, 4-5 institutions will be randomly selected or determined. Additionally, one of the top-three designated chain pharmacies by medical insurance fund usage in each inspected city will also be subject to inspection.
The inspection will focus on five key areas within designated medical institutions:
- Critical care medicine, anesthesia, and lung tumors, where the misuse of medical insurance funds and insurance fraud will be investigated and penalized.
- Previous key areas of self-inspection and self-correction, including cardiovascular medicine, orthopedics, blood purification, rehabilitation, medical imaging, and clinical testing.
- Ensuring that issues identified in previous inspections within designated medical institutions have been resolved.
- Online procurement of drugs and medical consumables, verifying whether public medical institutions are purchasing all required items in compliance with regulations.
- Investigating the misuse of medical insurance funds for patients seeking cross-provincial and regional treatment.
For designated retail pharmacies, the inspection will focus on three key areas:
- False drug purchases, forged prescriptions or expense lists, and misuse of medical insurance cards or electronic medical insurance vouchers.
- Participation in the resale of medical insurance drugs.
- Swapping drugs, which involves exchanging non-National Reimbursement Drug List (NRDL) drugs or goods for NRDL drugs for medical insurance settlement, and falsifying or altering related documents.- Flcube.com
