地方医保“50元”限额背后：门诊基金监管的两难处境

Core Viewpoint - The recent decision by Xinxiang, Henan to impose daily payment limits on outpatient services has sparked public concern, but the local health insurance bureau has announced the cancellation of these limits effective November 12, 2025, highlighting the challenges in outpatient fund regulation [1][2]. Group 1: Outpatient Fund Regulation Challenges - The rapid increase in outpatient visits, totaling 57.49 billion in 2024 compared to 48.7 billion in 2023, poses significant regulatory challenges for health insurance funds [2][3]. - The primary difficulty in outpatient fund regulation is the vast number of outpatient visits across numerous healthcare facilities, making comprehensive oversight impractical [2][3]. - The lack of effective regulatory standards for specific treatment projects, such as traditional Chinese medicine, creates opportunities for fund misuse [2][3]. Group 2: Fraudulent Practices and Regulatory Responses - Innovative and covert fraudulent practices, such as altering treatment codes and substituting non-insured drugs for insured ones, complicate timely detection by traditional regulatory methods [3][4]. - The annual payment limits for outpatient services are relatively low for residents, while the limits for employees can reach thousands, making employee outpatient services more susceptible to fraud [3][4]. - Local health insurance bureaus have issued warnings against end-of-year spending sprees, where some healthcare providers may exploit the misconception that unused insurance funds will expire [4][5]. Group 3: Recommendations for Improvement - Research indicates that the current outpatient fund regulation faces challenges such as underdeveloped intelligent oversight systems, low electronic medical record usage, and insufficient collaboration among regulatory bodies [7]. - Recommendations include advancing intelligent regulatory systems, enhancing the electronic documentation of outpatient visits, and improving the professional capacity of regulatory personnel [7].