医保智能监管的价值，不仅是查处违法违规行为，更在于以"数"惠民。我们要运用大数据分析技术，做 好定点医药机构药品价格的监测比对，让药品价格更加透明，便于职工群众做出更好选择；用智能手段 赋予健康"数字户口"，建好职工群众的医保健康档案，整合既往病史、诊疗记录、健康监测数据等，为 参保人提供个人"医保画像"，提供更为精准的医疗保障服务，让智慧医保"飞入寻常百姓家"。 监管为民，服务于民。我们要以技术创新、服务优化为抓手，持续升级医疗服务体系，为职工群众织就 更加全面、优质、高效的医疗保障网络，切实把群众的"救命钱"管好、守好，切实提升广大参保群众的 获得感、幸福感、安全感。 智能监管不是束缚，而是赋能。对定点医药机构来说，医保智能监管系统就是"天眼"，能对医保基金违 法违规使用行为进行"精准打击"，有效识别疑似不合理用药、不合理诊疗、重复收费等违规行为，形成 发现问题、反馈问题、纠正问题的良性循环；对医保管理部门而言，医保智能监管系统就是"工具箱"， 这一事前提醒、事中审核、事后监管的全流程、全链条医保基金安全防控体系，让医保基金监管更科 学、更主动、更有力。 智能化的关键，是通过技术赋能，有效解决问题。传统的 ...

2025年，兵团医疗保障局强化部门协同，积极开展日常检查、专项抽查、联合检查、飞行检查等多种形 式的检查，并同步应用医保智能监管系统、反欺诈大数据监测平台，对定点医药机构进行立体式、全覆 盖监管，不仅实现了对传统骗保行为的精准识别，更将监管触角延伸至门诊慢特病、DRG付费等领 域，有效防范了冒名就医（购药）、空刷套现、串换药品（项目）等欺诈骗保行为的发生。 同时，兵团还加快推进药品耗材追溯码的采集应用，精准打击"回流药"等乱象，对违规定点医药机构通 过解除协议、行政处罚等方式，形成查处一案、警示一片的强力震慑。2025年，兵团对100家违规定点 医药机构解除了医保服务协议，作出行政处罚36例，纳入信用管理重点监控45家，支付资格记分1017 人，对66名参保人给予签订承诺书、提高起付线等分级处理。 本报乌鲁木齐讯（全媒体记者 郑娅莉） "您好，您最近几个月的降压药已经开过了，不能再开了。"1月 22日，企业退休职工徐大爷在八师石河子市一家定点零售药店购药时，工作人员根据系统预警向徐大爷 作出提示。原来，徐大爷前段时间在另外一家药店一次性购买了3个月的降压药，系统对这一异常行为 进行了实时识别。 "当参保患者到 ...

Core Insights - The Shandong Provincial Government is implementing significant reforms in the medical insurance system during the 14th Five-Year Plan period, focusing on building a multi-level medical security system that includes basic medical insurance, major illness insurance, and medical assistance [1] Group 1: Medical Insurance Reforms - The Shandong Provincial Medical Insurance Bureau has initiated a series of measures to enhance the medical insurance experience for residents, resulting in lower medical expenses and more convenient access to healthcare [2] - The province has started the provincial-level coordination of employee basic medical insurance, standardizing the contribution rates and unifying reimbursement policies for outpatient and inpatient services [2] - The reimbursement levels for inpatient care are approximately 70% for insured residents and over 80% for employees, with ongoing improvements to outpatient chronic disease coverage [2] Group 2: Major Illness Insurance and Medical Assistance - The major illness insurance program has standardized the threshold for reimbursement, with a segmented reimbursement rate exceeding 60%, allowing for a maximum reimbursement of 400,000 yuan per medical year [3] - Vulnerable groups, including low-income individuals and those at risk of poverty, can receive subsidies for personal contributions and medical expenses, with the annual assistance limit raised to over 50,000 yuan [3] Group 3: Cross-Province Medical Services - The direct settlement rate for cross-province hospitalization has reached 94.49%, a significant increase from less than 50% during the previous Five-Year Plan [4] - The province has achieved full coverage for ten types of outpatient chronic diseases in terms of cross-province direct settlement, surpassing national targets by three years [4] - A comprehensive grassroots service network has been established, with 35,000 grassroots medical insurance workstations operational, ensuring coverage at all administrative levels [4] Group 4: Intelligent Supervision of Medical Insurance - The Shandong Provincial Medical Insurance Bureau has implemented an intelligent supervision system with 254 standardized rules to enhance oversight and prevent misuse of medical funds [5] - The system includes proactive alerts for unreasonable medical practices, which have helped prevent and reduce improper medical expenses by 4.125 billion yuan [5] - Ongoing audits and post-settlement supervision are in place to identify and address high-risk behaviors and fraudulent activities within the medical insurance system [6]