浅谈医疗机构该如何看待及应用医保基金“两库”

Core Viewpoint - The release of the intelligent supervision rule library and knowledge base by the National Medical Insurance Administration is crucial for enhancing the management and compliance of medical insurance funds, leveraging digitalization and intelligence to support comprehensive and multi-layered information management in the healthcare sector [1][2][5]. Group 1: Promotion of Intelligent Supervision - The top-level design for intelligent supervision is guided by several key documents from the central government, indicating a clear direction for reform in medical insurance fund management [2]. - Local pilot projects for intelligent monitoring began in 2019, providing valuable experience for the implementation of these systems [2]. - The management approach established in 2022 outlines the functions, principles, and responsibilities related to the rule and knowledge libraries, serving as a foundational guideline for local medical insurance departments [2][4]. Group 2: Technical and Operational Framework - In May 2023, the national version 1.0 of the rule and knowledge libraries was publicly released, creating a unified framework for intelligent supervision across the country [4]. - In September 2023, a notice was issued to further advance intelligent auditing and monitoring, addressing challenges in system construction and application [4]. Group 3: Impact on Medical Institutions - The implementation of the rule and knowledge libraries is expected to enhance compliance among designated medical institutions, reducing the occurrence of non-compliant use of medical insurance funds [5][7]. - The relationship between medical services and medical insurance is symbiotic, with medical insurance playing a significant role in promoting healthcare development by alleviating the financial burden on patients [6]. - The libraries set clear boundaries for medical insurance supervision, fostering a healthy industry environment and encouraging medical institutions to adopt more valuable and efficient medical technologies [7]. Group 4: Internal Management of Medical Institutions - The availability of the rule and knowledge libraries provides a framework for internal management within medical institutions, allowing leaders to better oversee compliance with medical insurance policies [9][11]. - Some managers have successfully integrated the libraries into their hospital information systems, enabling real-time compliance checks during medical procedures and billing [11]. - The external supervision by medical insurance departments complements the internal management of medical institutions, aiming to ensure that every penny of the medical insurance fund is spent effectively [12].