国家医保局明确2026年医疗保障基金监管工作安排 AI赋能破解监管难点

Core Viewpoint - The National Healthcare Security Administration (NHSA) has issued a notice outlining nine key tasks for the regulation of the medical insurance fund in 2026, emphasizing the importance of maintaining a high-pressure regulatory environment to ensure the safety of the medical insurance fund [1][2]. Group 1: Regulatory Measures - The notice emphasizes the continuation of special rectification of prominent issues in medical insurance fund management, with local healthcare departments required to ensure accountability at the highest level and implement multiple measures to enhance rectification efforts [1]. - A comprehensive expansion and quality improvement of flying inspections will be promoted, covering all provinces and various stakeholders, including designated medical institutions and insured individuals, across different types of insurance [1]. Group 2: Technological Innovations - The notice highlights the exploration of innovative applications of cutting-edge technologies such as artificial intelligence in regulatory practices, including the development of big data regulatory models to address challenges associated with DRG/DIP payment methods [2]. - The integration of artificial intelligence with imaging recognition is proposed to accurately identify irregularities in implanted medical materials and fraudulent medical practices [2]. Group 3: Systematic Improvements - The notice calls for the continuous improvement of a comprehensive intelligent regulatory system, aiming for over 70% of designated medical institutions to be connected to a pre-reminder system by the end of 2026 [2]. - It also emphasizes the need to establish long-term regulatory mechanisms, including the development of detailed implementation rules for the supervision of medical insurance fund usage and the management of personal accounts in retail pharmacies [2].