线索征集确定三大范围：一是倒卖医保"回流药"问题线索；二是违规超量开药问题线索；三是生育津贴 骗保问题线索。医疗保障行政部门对符合奖励条件的举报人按照案值的一定比例给予一次性资金奖励， 最高可达20万元，最低不少于200元，具体参照全省各地《举报奖励办法实施细则》。 为严厉打击欺诈骗保和违法违规使用医保基金行为，维护医保基金安全和参保群众合法权益，根据国家 医疗保障局《关于开展医保基金管理突出问题专项整治"百日行动"的通知》及相关工作部署，10月14 日，广东省医疗保障局发布公告，从即日起至2025年12月底，面向社会公开征集本省医保基金管理突出 问题专项整治"百日行动"线索。 ...

跨省就医结算方便了患者，但不少地方却在为医保基金"失血"发愁。 如何打破留不住病人、医保基金外流加剧、本地医院医保预算遭到挤压、床位闲置成本空转、医疗服务能力缺少资金支持的恶性循环，是摆在医保基金流 出省份面前的难题。 近年来，跨省异地就医直接结算的人次和费用总额持续攀升。由于毗邻上海、南京、杭州，以往，不少安徽市民选择"小病外治"。但该省的副中心城市芜 湖最新晒出的"成绩单"却显示了不一样的趋势——该市去年转外就医备案人数同比减少1.2万人次，留芜治疗率同比增加近四成。 是什么让这个以往被虹吸的城市留得住病人？近日，《每日经济新闻》记者带着这个疑问，跟随国家卫健委前往芜湖市调研采访。 此前芜湖异地就医医保基金支出压力较大 异地就医，指患者在非参保地就医，但医保费用支出责任仍由参保地承担。现实中，有这样一种情况，医疗水平相对薄弱地区的患者，因对本地医疗能力 缺乏信心或了解，小病也要前往大城市就医。 社交媒体上有不少相关的经验分享图片来源：网络截图 这会出现哪些问题？ 首先，经济发达地区的医疗项目定价普遍较高，且部分医生对异地患者缺乏控费动力。对患者来说，舟车劳顿的同时，还要支付更高的医疗费用。对参保 地医保系 ...

Core Insights - The National Healthcare Security Administration (NHSA) has issued a notice to address the issue of "dual pricing" in designated retail pharmacies, where prices for insured patients are higher than for non-insured patients [1][2][3] Group 1: Regulatory Actions - The NHSA has mandated local healthcare departments to monitor and address the "dual pricing" behavior in pharmacies, emphasizing that such practices violate agreements and harm insured patients [3] - Pharmacies found to be engaging in "dual pricing" may face serious consequences, including suspension of medical insurance settlements and potential legal actions [3] Group 2: Market Implications - The practice of "dual pricing" is seen as a form of price fraud that disrupts the pharmaceutical market and infringes on the rights of insured individuals [4] - Experts suggest that improving the efficiency of medical insurance settlements could alleviate financial pressures on pharmacies and reduce the occurrence of "dual pricing" [4][5] Group 3: Financial Considerations - The NHSA's notice highlights the need for pharmacies to conduct self-inspections and rectify discriminatory pricing practices promptly [3] - The implementation of an immediate settlement reform for basic medical insurance is expected to significantly reduce the accounts receivable issues faced by pharmacies, thereby enhancing their operational environment [4][5]

审计发现部分医院违规收费及多结算医保基金约1.5亿元 一些医院违规收费及多结算医保基金违规行为再次被审计部门发现。 近期26个省份审计部门陆续公开当地2024年度省级预算执行和其他财政收支的审计工作报告（下称"审 计报告"），其中，7个省份审计部门发现医院违规收费及多结算医保基金合计约1.5亿元。 湖南审计报告重点审计20家医院发现，有11家医院通过重复收费、分解住院、过度诊疗等方式违规收费 4684.89万元。 湖北审计报告称，8家医院采取虚计数量、以低充高、串换或拆分项目等方式，多结算医保基金2378.23 万元；6家医院采取分解住院、人为修改患者诊断结论等方式，多结算医保基金2739.01万元。8家医院 违规开展过度检查、开具"大处方"等，多收费1142.99万元；5家医院超标准多收药品及医用耗材费用 292.29万元。 黑龙江审计报告指出，部分公立医院存在违规收费问题。10家公立医院通过虚计药品耗材或诊疗项目、 串换药品耗材、诊疗项目"以低充高"等方式违规收费。 江西审计报告发现，部分医院违规多收诊疗费或多获医保基金结算。河南审计报告称，部分公立医院不 同程度存在重复收费、加价销售药品等问题。 目前， ...

Group 1 - The National Healthcare Security Administration (NHSA) has initiated a "100-day action" to address prominent issues in medical insurance fund management, focusing on illegal practices such as the resale of medical insurance drugs and fraudulent prescriptions [1] - The NHSA has launched a special investigation into excessive prescription practices, monitoring abnormal prescription behaviors and mismatches between prescriptions and diagnoses [1] - The NHSA is also targeting fraudulent claims related to maternity benefits [1] Group 2 - The NHSA has released a trial version of the "National Long-term Care Insurance Service Project Directory," which standardizes service items and payment scope for long-term care insurance [3] - The directory categorizes services into two main types: daily living care and medical care, with specific activities outlined under each category [3] - Regions starting new long-term care insurance programs must adhere strictly to the directory and cannot arbitrarily change the service scope [5] Group 3 - The NHSA is exploring the inclusion of intelligent services and supportive assistive devices related to long-term care in the payment scope [6] - Currently, nearly 190 million people are enrolled in China's long-term care insurance, with over 100 billion yuan accumulated in funds and expenditures exceeding 85 billion yuan [8] - During the 14th Five-Year Plan period, the program has benefited over 2 million individuals with disabilities [8]

Core Viewpoint - The National Healthcare Security Administration (NHSA) has initiated a "100-day action" to address prominent issues in medical insurance fund management and long-term care insurance services, effective immediately until December 31 of this year [1] Group 1: Medical Insurance Fund Management - A comprehensive governance initiative will be launched to tackle the issue of reselling medical insurance drugs, focusing on fraudulent practices by designated medical institutions, including falsifying prescriptions and illegal sales of medical insurance drugs [1] - The action will include special investigations into excessive prescription practices, monitoring abnormal prescription and purchase behaviors through drug traceability code data [1] - There will be a targeted effort to combat fraudulent claims related to maternity allowances [1]

Core Viewpoint - The National Medical Insurance Administration has launched a "100-day action" to address prominent issues in medical insurance fund management, aiming to eliminate illegal practices related to the resale of medical insurance return drugs by designated institutions by December 31, 2025 [1] Group 1: Focus Areas of the Action - Comprehensive governance of the resale of medical insurance return drugs, targeting issues such as falsifying prescriptions, fraudulent use of medical insurance vouchers, and illegal sales by professional prescribers and insured individuals [2] - Special investigation into excessive prescription practices, monitoring abnormal prescription and purchase behaviors, and identifying potential collusion in obtaining medical insurance drugs [3] Group 2: Specific Issues Addressed - Special governance of maternity allowance fraud, focusing on the verification of false documentation, fictitious employment relationships, and inflated payment bases to recover misappropriated medical insurance funds [4] - Emphasis on increasing punitive measures against identified illegal activities, with a commitment to publicize cases and educate the public on the consequences of such fraud [4]

Core Points - The Beijing Anzhen Hospital held a conference on July 28, 2023, to promote the "Standardized Diagnosis and Treatment Behavior, Reasonable Use of Medical Insurance Fund" initiative for 2025, in line with the directives from the central government [1][15] - The conference aimed to enhance the management of medical insurance funds and ensure their safe and reasonable use, addressing issues of corruption and improper practices in medical services [1][9] Group 1 - The hospital established a "Responsibility Letter for Standardized Diagnosis and Reasonable Billing" in accordance with the requirements of the Beijing Medical Insurance Service Agreement [3] - Representatives from five party branches signed the responsibility letter, committing to prioritize the safety of medical insurance funds alongside medical safety [3] - The hospital recognized 10 individuals as "Outstanding Medical Insurance Managers" and 10 as "Outstanding Price Managers" for their proactive and responsible work in managing medical insurance risks [3] Group 2 - The hospital's Vice President, Cai Jun, highlighted the establishment of a smart, professional, and standardized medical insurance management system, which has improved staff awareness of policies and risk management [7] - The hospital's Party Secretary, Zhang Hongjia, emphasized the importance of understanding the complexity and sensitivity of medical insurance work, urging strict adherence to regulations and the establishment of a robust management system [9] - A report on the practical enforcement of medical insurance fund supervision was presented, warning against fraudulent practices and emphasizing the need for professional integrity [11] Group 3 - Training sessions were conducted on topics such as standardized diagnosis behavior, medical insurance payment qualification management, and pricing billing [14] - The conference aimed to promote legal, compliant, and reasonable diagnostic services across all clinical and technical departments, reinforcing the responsibilities of department heads and medical staff [14] - The hospital plans to continue guiding staff to adhere to diagnostic norms and protect the integrity of the medical insurance fund, ensuring patient rights are upheld [14]

Core Insights - The article highlights the improvements in the healthcare insurance system in Baoji City, emphasizing reduced costs and increased transparency for patients [1][2][3][4][5][6] Group 1: Fund Management and Efficiency - Baoji City has implemented a multi-faceted approach to enhance the safety and efficiency of the medical insurance fund, including revenue generation, scientific management, and regulatory measures [1][2][3] - The average monthly contribution for employed individuals has increased by 550 yuan, resulting in an additional 120 million yuan in the employee medical insurance fund over the year [2] - The city has achieved a participation rate of 96.8%, with 3.1034 million insured individuals [2] Group 2: Cost Reduction and Patient Benefits - The introduction of a disease-based payment reform has led to a 10.5% decrease in average hospitalization costs, with a 14% reduction in medical insurance fund expenditures and an 8% decrease in personal financial burden [3] - The cumulative balance of the urban residents' medical insurance fund can cover 7.35 months of payments, placing Baoji City in a leading position within the province [4] Group 3: Smart Regulation and Oversight - The launch of a smart medical insurance regulatory platform has improved oversight of 1,380 retail pharmacies, significantly reducing fund expenditures by 466.4 million yuan, a 40% decrease [5] - The platform allows for real-time tracking of drug prices and sources, enhancing transparency and consumer protection [5] Group 4: Anti-Corruption Measures - Baoji City has intensified efforts to combat fraud in the medical insurance sector through stringent regulatory measures, including joint inspections and smart monitoring [6] - The city has adopted a comprehensive approach to safeguard the medical insurance fund, ensuring that resources are used effectively and efficiently [6]

Core Insights - The meeting held on July 16 focused on reviewing the performance of the provincial medical insurance system in the first half of the year and planning for the second half [1] Group 1: Performance and Achievements - The provincial medical insurance system has made steady progress in reform, management, and service optimization, with improvements in both quality and efficiency [2] - Key reforms include the implementation of the provincial adjustment fund system, payment method reforms, and the dynamic adjustment of medical service prices [2] - Special initiatives have been effectively carried out, including the rectification of issues in medical insurance fund management and the crackdown on fraudulent activities in the pharmaceutical sector [2] Group 2: Future Focus and Strategies - The provincial medical insurance system aims to enhance the balance between development and safety, improve fund management, and expand the coverage of medical institutions [3] - There is a strong emphasis on integrating medical insurance work into broader development strategies and improving the resilience and efficiency of fund operations [3] - Long-term planning is essential, with a focus on institutional development and optimizing management practices to ensure effective service delivery [3] Group 3: Collaborative Efforts and Innovations - The meeting highlighted the importance of collaboration among various departments and the need for continuous innovation in medical insurance practices [4] - Observations were made at various local facilities to assess innovative practices and their effectiveness in improving medical insurance services [4]