在乌苏市时珍堂大药房深入了解企业涉企检查、价格公示、医保基金专项整治；在御景湾小区查看充电 桩价格公示、计量检定，乌苏市共有9家电动自行车充电桩经营主体，分布在全市80个住宅小区，充电 桩设置195个点位，充电端口1952个，乌苏市充电桩已全部实现价费分离，建立长效监管机制，定期开 展"回头看"，形成闭环管理，巩固成果，让消费者明明白白消费；在乌苏市汇仁粮油购销有限责任公司 查看价格公示、在用的电子汽车衡、谷物容重器、水分测定仪等计量器具按时检定，并建立计量器具档 案，深入了解夏粮收购专项整治工作努力营造诚信、守法、公正、和谐的市场计量秩序，打好夏粮收 购"主动仗"推进情况；前往乌苏市祥庆烟花爆竹有限责任公司查看企业落实工业产品质量安全主体责 任、价格公示、"日管控、周排查、月调度"制度，提升产品质量管控能力，严把烟花爆竹产品质量进货 检查验收关，进一步规范烟花爆竹产品质量安全和价格经营行为给予充分肯定和高度评价，就进一步加 强推进涉企检查、价格公示、计量检定、夏粮收购、医保基金、旅游市场专项整治、质量监管提出了指 导性的意见，为新疆经济高质量发展贡献力量。 （杜志锋 张春齐 景道燕 ） 7月10日上午，自治 ...

Group 1 - The article highlights the ongoing efforts in Taizhou's Hailing District to ensure the safe use of medical insurance funds through a special rectification campaign aimed at preventing fraud and misuse [1] - A three-tiered supervision mechanism has been established involving the district's disciplinary inspection and supervision commission, functional departments, and medical institutions, leading to the investigation of 15 corruption and misconduct cases, with 8 individuals formally charged [1] - The campaign is part of a broader initiative to protect the integrity of medical insurance funds, which are crucial for the public's well-being [1] Group 2 - The Taizhou Fourth People's Hospital has implemented a "one-stop service" for chronic disease management, significantly reducing processing time from 5 working days to immediate completion, serving approximately 12,000 people annually [2] - A new prescription management model has been introduced, allowing for an average of over 200 prescriptions to be processed daily, covering 70% of chronic disease patients, while also preventing fraudulent prescriptions [2] - The hospital has adopted a multi-modal real-name medical system to combat the misuse of medical insurance cards, enhancing patient identification through facial recognition and ID verification [2] Group 3 - A regional testing center has been established to address the issue of repeated medical examinations, which is expected to reduce over 600 duplicate tests monthly, saving more than 200,000 yuan in medical expenses and insurance funds annually [3] - The district's disciplinary inspection and supervision commission emphasizes the dual role of safeguarding medical insurance funds while protecting the interests of the public [3] - Future efforts will focus on deepening the results of the special rectification campaign and establishing a long-term regulatory mechanism for medical insurance funds [3]

Core Insights - The phenomenon of "one drug, two prices" in pharmacies is drawing significant consumer attention, particularly regarding the price discrepancies between in-store purchases using health insurance cards and online prices [1][2] - Consumers are struggling to understand the rationale behind these price differences, especially when they are using funds from their health insurance accounts [1] - The issue is partly attributed to the longer settlement periods associated with health insurance payments, which may lead pharmacies to pass on costs to consumers [1] Group 1 - The media has reported on a consumer's experience of purchasing medication at a pharmacy with a health insurance card, only to find that the prices were significantly higher than those available online [1] - There is a growing concern that some pharmacies may be exploiting the "one drug, two prices" model as a means to siphon off health insurance funds, especially if other pharmacies follow suit [1] - The National Healthcare Security Administration has initiated measures to improve the efficiency of health insurance settlements with designated medical institutions, which may help address these pricing discrepancies [1] Group 2 - The ongoing issue of "one drug, two prices" cannot continue, and there is a call for stricter enforcement, improved settlement efficiency, and heightened public awareness [2] - Pharmacies that focus on exploiting consumers rather than providing competitive pricing may face the risk of being driven out of the market due to increasing competition from online sales and other pharmacies [2]

据《工人日报》报道，"一款药物为何两种价格？"近日，来自重庆的邓女士表示，自己在当地一家 药店购买三黄片(葵花)，店员告知售价为18元一盒，结账时，邓女士掏出医保卡准备付款，收银员见状 提醒她，刷医保个人账户比付现金贵，需要支付26元。据了解，邓女士的经历并非个案。不少参保人在 医保定点药店购药均遭遇"阴阳价"，同一款药，刷医保个人账户比付现金贵。 药店作为零售药的主要市场主体，追求利润最大化本无可厚非，但通过"阴阳价"实现这一目标，就 属于投机取巧。由于医保结算回款需要时间，存在周期性延迟现象，药店需先行垫付统筹基金报销部 分，还要承担2%-3%的手续费，资金回笼压力导致部分商家将成本转嫁给消费者。药店的"阴阳价"策略 之所以能够实施，则是利用了参保人对医保个人账户资金敏感度较低的心理，当现金支付与医保支付价 格悬殊时，消费者就会陷入"不用医保亏钱，用了更亏"的两难境地。 对于"阴阳价"，完善制度设计是治本之策。今年1月，国家医保局发布的《关于推进基本医保基金 即时结算改革的通知》，提出推进医保与定点医药机构即时结算，为定点医药机构运行持续注入流动资 金。加速推进医保基金即时结算改革，通过缩短结算周期、降低 ...

Core Viewpoint - The article discusses the phenomenon of "dual pricing" in pharmacies, where the price of a medication differs significantly depending on whether a consumer pays with cash or through their medical insurance card, raising concerns about fairness and transparency in pricing practices [1][2][3] Group 1: Pricing Discrepancies - A specific case is highlighted where a medication priced at 18 yuan costs 26 yuan when paid for with a medical insurance card, representing a nearly 50% increase [1] - This pricing discrepancy is not isolated, as similar experiences have been reported by other consumers in different regions, indicating a potential widespread issue [1][3] Group 2: Cost Transfer and Justifications - One explanation for the price difference is the longer settlement period for medical insurance payments, which incurs a 2% to 3% fee that pharmacies may pass on to consumers [2] - However, this rationale is questioned, as the extent of the price increase cannot be solely attributed to these fees, suggesting that pharmacies may be exploiting the situation for additional profit [2] Group 3: Consumer Impact and Perception - Consumers express frustration over the higher costs associated with using their medical insurance cards, feeling that they are unfairly penalized despite the funds being their own [3] - The article warns that if such pricing practices are normalized, it could lead to broader skepticism about the medical insurance system and diminish consumer confidence in participating in insurance programs [3] Group 4: Regulatory Concerns - The article calls for regulatory scrutiny of these pricing practices, emphasizing that consumers should not be subjected to discriminatory pricing and that medical insurance funds should not be exploited [3]

Core Viewpoint - The National Medical Insurance Administration (NMIA) has launched a nationwide campaign to combat fraud and illegal activities in the pharmaceutical sector, utilizing drug traceability codes as a key tool, and has announced eight typical cases of fraud [1][2]. Group 1: Fraud Cases - Eight typical cases of fraud have been identified, including: - A pharmacy in Lanzhou, Gansu Province, involved in card swiping and reselling medical insurance drugs [1]. - Nine pharmacies in Wuhan, Hubei Province, participating in the resale of medical insurance drugs [1]. - A pharmacy in Changsha, Hunan Province, that forged prescriptions to defraud medical insurance funds [1]. - A pharmacy in Fuzhou, Jiangxi Province, involved in swapping and reselling medical insurance drugs [1]. - A clinic in Hefei, Anhui Province, that illegally purchased and resold drugs from online retail platforms [1]. - A chain company in Yangquan, Shanxi Province, that induced false drug purchases [1]. - A doctor in Xi'an, Shaanxi Province, who prescribed excessive medications and issued illegal prescriptions [1]. - An insured individual in Shanghai who purchased excessive medications [1]. Group 2: Role of Drug Traceability Codes - Drug traceability codes serve as a unique "electronic ID" for each box of medication, essential for ensuring compliance in procurement and settlement processes [2]. - All medical insurance designated institutions are required to procure drugs with traceability codes and settle payments via scanning [2]. - The NMIA encourages insured individuals to use the national medical insurance app to scan the traceability codes on drug packages to protect their legal rights against suspected fraudulent activities [2].

以下文章来源于21新健康 ，作者韩利明 21新健康 . 21世纪传媒 · 公众号矩阵成员。 作 者丨韩利明 编 辑丨季媛媛 日前，湖南省医保局官网发布《关于开展2025年医疗保障基金省级飞行检查的通告》（下称 《湖南医保飞检》）， 明确于2025年7月至9月开展医保基金专项检查，全面核查2023 年1月1 日至2025年6月30日期间医保基金使用情况 。 作为人民群众的"看病钱""救命钱"，医保基金安全关乎每一位参保者的切身利益。今年1月， 国家医保局便已提前部署，启动2025年定点医药机构违法违规使用医保基金自查自纠工作， 首次将自查主体从定点医疗机构拓展至定点医疗机构和定点零售药店两类。 随着自查自纠工作进入尾声，4月起，国家医保局以"四不两直"（不发通知、不打招呼、不听 汇报、不用陪同接待，直奔基层、直插现场）的检查方式，对全国定点医药机构开展飞行检 查。 与此同时，省级层面的医保飞检工作也在紧锣密鼓推进， 辽宁、河南、河北、福建、上海等 多地已相继官宣启动省级飞检 ，检查对象覆盖定点医疗机构、定点零售药店、参保人及医保 经办机构，且均沿用"四不两直"模式，检查内容与形式相较往年更为全面细致，彰显出强化 ...

Core Viewpoint - Hainan Province has innovatively implemented a direct settlement system for medical insurance funds, significantly reducing the payment cycle for pharmaceutical companies from an average of one year to less than 30 days, thereby addressing the long-standing issue of slow payment in the pharmaceutical industry [2][3][4]. Group 1: Direct Settlement Implementation - The direct settlement system allows pharmaceutical companies to receive payments quickly, as demonstrated by a case where a company received 32,691.2 yuan within a month instead of the previous one-year wait [2]. - The initiative has expanded the direct settlement scope to include all drugs and consumables purchased through the provincial medical procurement platform, enhancing the stability of drug supply and meeting public healthcare needs [2][3]. - Since the launch of the online payment system on December 2, 2024, Hainan has directly settled approximately 2.409 billion yuan for 481 pharmaceutical companies, further reducing the average payment cycle to 30 days [4]. Group 2: Financial Relief for Hospitals - To alleviate the financial pressure on hospitals, Hainan has implemented a system of monthly pre-settlement, allowing hospitals to receive 90% of their declared medical expenses the day after submission [6]. - A prepayment management mechanism has been established, enabling eligible hospitals to apply for an additional month's worth of medical expenses on top of the monthly pre-settlement [6]. - The new system simplifies the reconciliation process for hospitals, which previously had to coordinate with 19 different agencies, now only needing to interface with the Hainan Medical Insurance Service Center [6].

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].

医保基金作为保障人民群众健康权益的重要资金池，其安全、合理、高效运行成为全社会关注的焦点。然而，传统的基金监管方式已难以适应 数字化、智能化治理的要求，医保基金智能监管逐渐成为推进医保精细化管理、防范基金风险、构建可持续医疗保障体系的重要抓手。 2024 年，全国医保系统共追回医保基金275亿元，其中通过智能监管子系统挽回损失31亿元，充分彰显了智能监管的显著成效。笔者结合医保基金 监管的政策背景、现实需求，探讨医保基金智能监管的核心特征及未来发展路径，以期为医保基金安全高效运行提供参考。 医保基金智能监管的政策背景 医保基金使用涉及主体多、链条长、风险点多，监管难度大。为应对这些挑战，国家出台了一系列政策文件， 推动医保基金监管的数字化转 型。2021年，国家医保局等七部门联合印发《医疗保障基金使用监督管理条例》，构建了依法依规、全链条、全流程的基金监管制度体系。 2023年，国家医保局发布《关于进一步深入推进医疗保障基金智能审核和监控工作的通知》，明确提出到2023年底前全部统筹地区上线智能监 管子系统，初步实现全国智能监控"一张网"。此外，《医疗保障基金智能审核和监控知识库、规则库框架体系（1.0版）》 ...