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医保基金智能监管
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浅谈医疗机构该如何看待及应用医保基金“两库”
Sou Hu Cai Jing· 2025-07-03 12:45
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].
以智能监管赋能医保基金安全高效运行
Sou Hu Cai Jing· 2025-07-03 10:59
Core Viewpoint - The article emphasizes the importance of intelligent supervision of medical insurance funds as a crucial measure for ensuring the safe, reasonable, and efficient operation of these funds, highlighting its role in preventing risks and promoting sustainable healthcare systems [1][10]. Summary by Sections Policy Background of Intelligent Supervision - The complexity and risk associated with medical insurance fund usage necessitate a digital transformation in supervision, supported by various national policies [2]. - In 2021, the National Medical Insurance Administration and other departments issued regulations to establish a comprehensive fund supervision system [2]. - By the end of 2023, all regions are expected to implement intelligent supervision systems, creating a nationwide monitoring network [2]. Pain Points and Core Features of Intelligent Supervision - Intelligent supervision utilizes technologies such as big data, AI, cloud computing, and blockchain to create a comprehensive and dynamic regulatory system for medical insurance funds [4]. - Key features include data-driven approaches, closed-loop processes, and technology serving business needs, enabling real-time monitoring and rapid response to issues [4]. Pathways and Models for Intelligent Supervision System - Data governance is essential for establishing a robust intelligent supervision framework, requiring standardized data management and interconnectivity among various healthcare data sources [6]. - Emphasis on "human-machine collaboration" is crucial for enhancing regulatory precision and efficiency [6]. - The creation of an integrated intelligent supervision platform that fosters collaboration across multiple departments and levels is necessary for effective oversight [6]. Future Outlook and Recommendations - There is a need to improve legal frameworks and data standards to support intelligent supervision [7]. - The integration of intelligent supervision platforms should be accelerated to enhance cross-regional and cross-departmental collaboration [7]. - Strengthening talent development and technological innovation is vital for improving regulatory efficiency [9]. - Encouraging social collaboration in fund governance can create a supportive environment for safeguarding medical insurance funds [9]. - The trend towards proactive measures in intelligent supervision aims to prevent violations and enhance the overall quality of healthcare services [9]. Conclusion - Intelligent supervision is positioned as a foundational element for the safe and efficient operation of medical insurance funds, with a focus on digital transformation and public health [10].
大数据+AI,如何助力医保事业高质量发展?
Sou Hu Cai Jing· 2025-06-27 12:19
Group 1: AI Integration in Healthcare Services - The rapid development of AI technology is being integrated into healthcare insurance services, enhancing convenience and improving service quality for the public [1][2] - Various local healthcare insurance bureaus have adopted AI models like DeepSeek, enabling instant responses to frequently asked questions regarding insurance policies and reimbursement processes [2] - The AI assistant "依保儿" has been launched in multiple regions, significantly improving service efficiency and user experience, with an average monthly access of 37,500 visits in Hangzhou [2][3] Group 2: Challenges in Fund Supervision - The healthcare fund supervision faces significant challenges due to a lack of personnel compared to the vast number of insured individuals and healthcare institutions [4] - Traditional supervision methods are inefficient, with less than 1% of medical expense documents being manually audited, leading to difficulties in identifying fraudulent activities [4] - The need for modernized supervision through big data and AI applications is emphasized to address the extensive regulatory tasks and improve efficiency [4] Group 3: Smart Supervision Initiatives - The National Healthcare Security Administration has initiated the first batch of intelligent supervision rules and is promoting pilot reforms to enhance fund supervision [5][7] - By the end of 2024, the goal is to achieve full coverage of the intelligent monitoring subsystem across all healthcare institutions, particularly benefiting secondary hospitals and grassroots medical facilities [7] - The intelligent supervision system has been implemented in over 90% of the national healthcare regions, enhancing the monitoring capabilities of healthcare funds [5][7] Group 4: Data Utilization and Analysis - The healthcare sector possesses rich data resources that can optimize resource allocation, fund supervision, and drive innovation in the pharmaceutical industry [9] - In-depth data analysis has revealed unusual patterns, such as male patients receiving gynecological treatments, highlighting the importance of data scrutiny in preventing fund misuse [9][10] - Local healthcare departments are leveraging technology to improve data dissemination and analysis, with initiatives like the "医保高铁" platform in Nanjing, which integrates data from over 2,148 healthcare institutions [11] Group 5: Future Prospects - The application of AI and big data in healthcare is expected to expand, enhancing fund prediction models and improving efficiency [12] - Combining AI with blockchain technology could increase data transparency and traceability, thereby strengthening the credibility of the healthcare system [12] - AI and big data will play a significant role in chronic disease management, telemedicine, and personalized healthcare services in the future [12]
医保定点医院“新规范”!让每一分医保钱花得更有意义
Xin Hua Wang· 2025-06-24 11:06
Core Viewpoint - The National Healthcare Security Administration (NHSA) has issued a new notification to strengthen the management of designated medical institutions under the medical insurance system, aiming to ensure that every penny of medical insurance funds is spent meaningfully [1] Group 1: Entry Standards for Designated Medical Institutions - The notification specifies stricter application conditions for medical institutions seeking to become designated under the medical insurance system, including the mandatory use of drug and consumable traceability codes [2] - Newly designated institutions will undergo a 6-month trial period, during which compliance with relevant policies will be monitored, with potential extensions or terminations of agreements based on performance [2] Group 2: Daily Management and Monitoring - The NHSA has initiated intelligent supervision reforms to enhance the management of designated medical institutions, including pre-emptive reminders for uploaded expenses [2] - A "driving license" point system will be implemented for personnel at designated institutions, with penalties for accumulating points over a year [2] Group 3: Utilization of Medical Insurance Funds - The notification prohibits practices that force patients to purchase medications or supplies outside the hospital, ensuring that necessary medical services are not reduced [3] - Special provisions will be made for vulnerable groups, including separate designated facilities for low-income patients and monitoring for those with high hospitalization rates [3] Group 4: Exit Mechanism for Designated Medical Institutions - Clear criteria for the exit of designated medical institutions have been established, including actions that may lead to suspension or termination of agreements due to fraudulent activities [6] - Local healthcare departments are actively working on exit mechanisms, with processes in place for institutions that voluntarily withdraw from the program [6] - The NHSA emphasizes a comprehensive management approach from entry to exit, ensuring that medical insurance funds are effectively utilized [6]
国家医保局发布第一批医保基金智能监管规则和知识点 推动医保基金监管关口前移
Ren Min Ri Bao· 2025-05-25 21:57
Core Insights - The National Healthcare Security Administration (NHSA) has publicly released the first batch of intelligent supervision rules and knowledge points for medical insurance funds, aiming to enhance the regulation of medical insurance funds through a proactive reminder system [1][2]. Group 1: Intelligent Supervision Implementation - The intelligent supervision system is designed to identify and alert medical personnel of any violations during the prescription process, addressing issues before they escalate [1]. - The NHSA allows all designated medical institutions to access and utilize the intelligent supervision system for free, enhancing the efficiency and accuracy of preemptive reminders [1]. Group 2: Knowledge Base and Rules - The first batch of intelligent supervision rules includes over 10,000 detailed knowledge points across five categories, such as gender-specific drug usage and pediatric-specific medical services [1]. - The NHSA will continuously track, evaluate, and improve the knowledge base to ensure its scientific validity and accuracy [1]. Group 3: Dynamic Updates and Integration - Provincial healthcare departments are required to dynamically update their intelligent supervision systems based on the latest knowledge points and codes [2]. - Designated medical institutions are encouraged to integrate the intelligent supervision knowledge base into their own information systems to eliminate non-compliant behaviors at an early stage [2].