医保基金是老百姓的"看病钱""救命钱"，关系着千家万户的健康福祉和民生保障。近年来医保部门积极推进大数据和智能监管手段在基金监管 工作中的应用，智能监管已经成为医保基金监管的重要方式之一。 5月23日，国家医保局发布第一批"两库"规则和知识点，其中涉及药品区分性别使用、医疗服务项目区分性别使用、药品儿童专用、药品限儿 童使用、医疗服务项目儿童专用5类规则，共计11290条知识点明细。此举旨在杜绝临床上存在的超性别、超年龄范围不合理用药和诊疗行为， 进一步规范医疗服务行为，保障患者用药安全。7月22日，第二批"两库"规则和知识点发布，针对手术项目未按规定折价收费等问题发布378条 知识点明细，确保手术收费严格执行国家及地方定价、折价规定，要求各省结合本地项目目录细化，防止因收费不规范导致的基金浪费。紧接 着，7月30日发布的第三批"两库"规则和知识点则聚焦于药品限工伤保险、限生育保险两类规则，通过严格区分药品的限定支付范围，有效防 范工伤保险或生育保险基金用于支付非对应适应症药品的情况，确保专项基金精准使用。8月8日，第四批"两库"规则和知识点上线，包含736 条药品限就医方式规则对应知识点明细，该规则和知识点 ...

国家医保局发布通知，按照《国家医疗保障局办公室关于开展智能监管改革试点的通知》工作安排，经 定点医药机构自愿报名、各省级医保局推选、国家医保局筛选，确定试点地区92个(其中天津、河北、 山东、海南、贵州、青海、宁夏为全省域范围内试点)、试点定点医药机构359家(名单附后)。各省级医 保局要用好国家医保局分批次公开发布的智能监管"两库"规则及其知识点，做好智能监管改革试点工 作。一方面，推动智能监管"两库"在定点医药机构自建事前提醒系统中落地应用，将试点定点医药机构 建设成为国家医保局"两库"开发建设、公布公开的"试验田"，以及自查自纠的"标杆"。另一方面，推动 全省智能监管子系统应用成效提升，实现监管关口前移，从源头上减少使用医保基金违法违规行为发 生，使"两库"公开、智能监管成为定点医药机构主动合规的有效途径。 ...

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].