人民网北京12月13日电 （记者乔业琼）据国家医保局官网消息，今日，全国医疗保障工作会议在 北京召开，总结"十四五"时期医保工作，部署2026年工作。 会议要求，2026年，将持续加大飞行检查力度，实现全国所有统筹地区及各类基金使用主体全覆 盖，对患者自费率畸高且排名全国前列的统筹地区和定点医疗机构开展"点穴式"飞行检查，坚决维护人 民群众健康权益。坚决支持定点医疗机构根据诊疗需要对必需的医保目录内药品应配尽配。对倒卖"回 流药"等违法违规使用医保基金行为零容忍，坚决从严处罚。 会议指出，"十四五"时期，积极推进医药领域腐败以及群众身边不正之风和腐败问题集中整治，扎 实开展医保基金管理突出问题专项整治。全面开展"四不两直"飞行检查，实现全国所有省份全覆盖。5 年来共追回医保资金约1200亿元。创新开展药品追溯码采集和监管应用，累计归集追溯码超1000亿条， 有力打击通过倒卖"回流药"骗取医保基金等违法违规行为。 ...

2025年12月13日，全国医疗保障工作会议在北京召开。国家医保局方面披露，5年来共追回医保资金约 1200亿元。 国家医保局积极推进医药领域腐败以及群众身边不正之风和腐败问题集中整治，扎实开展医保基金管理 突出问题专项整治。全面开展"四不两直"飞行检查，实现全国所有省份全覆盖。5年来共追回医保资金 约1200亿元。创新开展药品追溯码采集和监管应用，累计归集追溯码超1000亿条，有力打击通过倒 卖"回流药"骗取医保基金等违法违规行为。 国家医保局方面表示，2026年，要进一步加强医保基金运行管理，守牢医保基金安全底线。持续加大飞 行检查力度，实现全国所有统筹地区及各类基金使用主体全覆盖，对患者自费率畸高且排名全国前列的 统筹地区和定点医疗机构开展"点穴式"飞行检查，坚决维护人民群众健康权益。坚决支持定点医疗机构 根据诊疗需要对必需的医保目录内药品应配尽配。对倒卖"回流药"等违法违规使用医保基金行为零容 忍，坚决从严处罚。 （文章来源：中国经营报） "十四五"时期，医保事业发展取得积极成效。 ...

每经AI快讯，据国家医保局网站消息，2025年12月13日，全国医疗保障工作会议在北京召开。会议指 出，"十四五"时期，积极推进医药领域腐败以及群众身边不正之风和腐败问题集中整治，扎实开展医保 基金管理突出问题专项整治。全面开展"四不两直"飞行检查，实现全国所有省份全覆盖。5年来共追回 医保资金约1200亿元。创新开展药品追溯码采集和监管应用，累计归集追溯码超1000亿条，有力打击通 过倒卖"回流药"骗取医保基金等违法违规行为。 ...

Group 1 - The core issue is the implementation of daily reimbursement limits for medical insurance in Xinxiang, with residents capped at 50 yuan and employees at 150 yuan, effective from June 13, 2025 [2][4] - The Xinxiang Medical Insurance Bureau stated that without these limits, the insurance fund could face a deficit by the end of the year, emphasizing the need for efficient fund management [4][6] - The adjustment aims to prevent fraud in the medical insurance system and to standardize medical practices in hospitals and clinics, with the bureau asserting that typical outpatient expenses are around 100 to 200 yuan per visit [7] Group 2 - The bureau clarified that the new limits are not indicative of a funding shortfall but are a preventive measure against fraudulent claims [6][7] - Patients needing to exceed the daily limit are encouraged to self-pay the excess amount, as splitting large expenses over multiple days is not compliant with insurance regulations [7]

Core Viewpoint - The Guangdong Provincial Medical Security Bureau has initiated a special action to combat fraud and illegal use of medical insurance funds, aiming to safeguard the integrity of the medical insurance fund and protect the rights of insured individuals [1] Group 1: Action Details - The special action, termed "Hundred-Day Action," will run from now until the end of December 2025, focusing on collecting clues related to prominent issues in medical insurance fund management [1] - Three main areas of concern for clue collection include: 1. Reselling of medical insurance "return drugs" 2. Excessive prescription of medications 3. Fraud related to maternity benefits [1] Group 2: Reporting and Rewards - The medical security administrative department will provide financial rewards to whistleblowers whose reports meet the criteria, with rewards ranging from a minimum of 200 yuan to a maximum of 200,000 yuan, based on the value of the case [1] - The specific implementation details for the reward system will refer to the local "Reporting Reward Implementation Rules" across the province [1]

Core Viewpoint - The article discusses the challenges faced by the medical insurance fund in provinces experiencing outflow due to cross-province medical treatment, highlighting the successful strategies implemented by Wuhu City to retain patients and reduce financial pressure on local healthcare systems [1][5][6]. Summary by Sections Cross-Province Medical Treatment Challenges - The increase in cross-province medical treatment has led to financial strain on local medical insurance funds, with patients often opting for treatment in economically developed areas where costs are higher [5][6]. - Wuhu City has historically been a region with significant patient outflow, with annual medical insurance fund outflow estimated at 500 million to 600 million yuan [6][7]. Wuhu City's Strategies - Wuhu City established consultation and referral management centers in 2023 to streamline patient care and reduce the outflow of patients seeking treatment elsewhere [8][10]. - The establishment of these centers has resulted in a 35% increase in the treatment rate of patients remaining in Wuhu, with a 73.87% increase in the number of out-of-province insured patients receiving treatment in the city [10][12]. Financial and Operational Improvements - The management center has successfully reduced the financial burden on the local medical insurance fund, achieving a reduction in external fund expenditures while enhancing local medical capabilities [10][12]. - The city has implemented a subsidy system for patients who choose to stay for treatment, including waiving or reducing the initial payment for hospital admissions [12][13]. Expert Consultation Initiatives - Wuhu has begun inviting external medical experts to provide consultations and surgeries locally, which helps reduce patient costs and saves on medical insurance funds [13][14]. - The financial structure allows for shared costs between the hospital and patients, with additional subsidies provided for inviting external experts, thereby encouraging local treatment [13][14].

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]

Core Insights - Recent audits across 26 provinces in China revealed that hospitals have engaged in illegal charging and overbilling of medical insurance funds, totaling approximately 150 million yuan [1][2] Group 1: Audit Findings - In Hunan province, 11 out of 20 audited hospitals were found to have illegally charged a total of 46.84 million yuan through methods such as duplicate billing and excessive treatment [1] - The audit in Hubei province identified 8 hospitals that overbilled medical insurance funds by 23.78 million yuan through false quantity reporting and other deceptive practices, while 6 hospitals were found to have overbilled by 27.39 million yuan through patient diagnosis manipulation [1] - In Hebei province, 9 public hospitals, including Hebei Medical University Fourth Hospital, were reported to have overcharged by 14.93 million yuan and overbilled medical insurance funds by 2.38 million yuan through various violations [1] Group 2: Regulatory Response - The National Medical Insurance Administration has intensified oversight and enforcement against fraudulent practices in medical insurance, with a focus on high-risk areas and institutions [2] - From January to June of this year, 335,000 medical institutions were inspected nationwide, resulting in the recovery of 16.13 billion yuan in medical insurance funds [2] - The implementation of intelligent regulatory systems has led to the rejection and recovery of 330 million yuan in medical insurance funds this year [2]

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]