“两库”规则和知识点“5连发”！医保基金智能监管提速——

Core Viewpoint - The National Healthcare Security Administration (NHSA) is advancing the intelligent regulation of medical insurance funds, emphasizing the importance of big data and smart supervision in ensuring the effective use of these funds [1][6]. Group 1: Historical Development of Intelligent Regulation - Since 2019, NHSA has initiated the construction of intelligent monitoring "demonstration points" across 32 cities, laying a solid foundation for the management of the knowledge and rules databases [2][3]. - In March 2022, NHSA issued a management approach for the intelligent audit and monitoring knowledge and rules databases, aiming to enhance regulatory efficiency and promote effective fund usage [2][3]. - The framework for the knowledge and rules databases was officially published in May 2023, marking a significant step towards a unified and transparent intelligent regulatory system [3][6]. Group 2: Implementation of the Knowledge and Rules Databases - The first batch of rules and knowledge points was released on May 23, 2023, covering 11,290 detailed knowledge points related to gender and age-specific medication and medical services [5]. - Subsequent batches addressed issues such as improper pricing for surgical projects and restrictions on drug usage for specific insurance types, ensuring compliance with national pricing regulations [5][6]. - The continuous release of these databases indicates a shift towards a more intelligent and refined regulatory phase for medical insurance funds [3][5]. Group 3: Importance of Intelligent Regulation - The traditional regulatory methods are becoming inadequate due to the increasing complexity and volume of healthcare data, necessitating a shift to intelligent monitoring systems [6][8]. - The establishment of a nationwide intelligent regulatory system is crucial for real-time tracking of fund usage behaviors, enhancing the protection of public healthcare funds [6][8]. - The intelligent regulation system serves as a first line of defense for medical institutions, promoting compliance and reducing the occurrence of fraudulent activities [9]. Group 4: Collaboration Between NHSA and Medical Institutions - The "two databases" are reshaping the relationship between NHSA and medical institutions, facilitating a win-win scenario through standardized and efficient management [9]. - Medical institutions can integrate the intelligent regulation databases into their systems, allowing for proactive compliance checks and reducing the likelihood of non-compliant behaviors [9]. - As these rules become embedded in hospital information systems, healthcare providers will receive real-time alerts to correct potential issues related to inappropriate prescriptions or charges [9].