context: The oversight of medical insurance funds has intensified in recent years. In 2023, retail pharmacies were included in spot checks for the first time, and incidents of hospitals committing insurance fraud have been frequently reported by healthcare authorities. On 27 September, NHSA (National Healthcare Security Administration), together with NHC (National Health Commission) and NMPA (National Medical Products Administration), issued Guidelines to establish a licence-style points system, tracking responsibilities from institutions to individual healthcare workers.
Yan Qinghui 颜清辉 NHSA (National Healthcare Security Administration) deputy director announced that nationwide spot checks now cover all provinces. The inspection of 500 designated medical institutions
- uncovered suspected violations involving C¥2.21 bn
- 185 institutions were identified with violations totalling C¥810 million
- 111 institutions committed fraud
- medical insurance departments at all levels recovered C¥13.66 bn in misused funds from January to August 2024
Despite various efforts, the deterrent effect remains limited. Gu Rong 顾荣 NHSA Fund Supervision Department director notes that the issue lies in the fact that
- penalties mainly target institutions, leaving individuals with little consequence
- often allows offenders to resume illegal activities with minimal changes to their operations
Gu explains that a medical insurance integrity file will be created for each individual associated with designated medical institutions. This ‘one person, one file’ system will comprehensively record their points and compliance with medical insurance laws and regulations throughout their career
- the point system ranges from 1–3 points, 4–6 points, 7–9 points and 10–12 points
- if a public medical institution unjustifiably uses high-cost, non-selected products beyond the prescribed requirements, it will result in a 1–3 point penalty
- should an individual accumulate 12 points within a calendar year, their medical insurance payment qualification will be revoked
The implementation of these policies requires coordination across multiple departments. Xing Ruoqi 邢若齐 NHC (National Health Commission) Medical Administration Bureau deputy director states the incoming measures include
- a review of cases with unusually high inpatient costs
- a long-term mechanism for tiered and layered monitoring and tracing
- ongoing supervision to regulate diagnosis, treatment and billing practices
- ensuring compliance with medical insurance fund usage, with large hospitals undergoing inspections to encourage better internal management
Cai Haiqing 蔡海清 Jiangxi Provincial Medical Insurance Bureau Treatment Security Division former director notes that
- many grassroots designated medical institutions and retail pharmacies have outdated Hospital Information Systems and lack adequate digital infrastructure
- information system functionality needs to be promptly developed
- data transmission interface standards between medical insurance systems and healthcare institution systems must be standardised