在违规超量开药问题核查方面，将紧盯药品追溯码数据监测异常的开药、购药行为，结合重点监测易倒 卖回流医保药品清单，重点核查远超临床合理用量违规开药、违规冒名购药等异常情形。 在生育津贴骗保问题治理方面，重点核查参保单位及个人伪造证明材料"造假申领"骗保、虚构劳动关 系"挂靠参保"骗保等情形。 国家医保局有关负责人表示，此次"百日行动"是医保基金管理突出问题专项整治"突击战"的重要行动安 排，各级医保部门要强化数智赋能、加强统筹协调、严格依法处置等，确保"百日行动"各项任务落地见 效。 新华社北京10月2日电（记者彭韵佳）为深入打击倒卖医保回流药等违法违规使用医保基金行为，国家 医保局在全国范围开展医保基金管理突出问题专项整治"百日行动"。 "百日行动"从2025年9月24日到2025年12月31日，聚焦倒卖医保回流药、违规超量开药、生育津贴骗保 三大重点任务，开展集中攻坚、精准整治，力争在全国范围内基本肃清倒卖医保回流药等问题。 在倒卖回流药问题治理方面，将重点查处定点医药机构伪造处方、空刷套刷医保凭证、串换医保药品、 诱导"回收"、诱导"冲顶消费"、不扫码销售，以及职业开药人和参保人非法售卖医保药品等问题。 ...

中国发展网讯一直以来，"购药贵、比价难"是群众在就医购药过程中面临的烦心事，而"监管难、决策 缺据"也困扰着医保部门的工作开展。为破解这些痛点，2023年伊始，山东省滨州市医保局主动作为、 大胆创新，精心打造了"医保价格掌上通"系统，成功构建起"数据驱动、服务便民、监管智能"的医药价 格管理新模式，为医药价格管理工作注入了数字化新活力。 截至目前，该系统已实现与全市3800多家定点医药机构的无缝对接，可提供查询的药品达6.55万种、耗 材2.27万种、医疗服务项目5731个。系统中的所有数据均从结算数据库即时接入，确保信息的实时性与 准确性。自上线以来，系统访问量已突破45万人次。 锚定"一体两翼三端"架构筑牢价格管理根基。全市统一医保价格数据库，汇总医院、药店两个端口数 据，涵盖药品、医用耗材、诊疗服务三个维度，包含进价、售价、数量三个核心指标，通过与医保核心 系统对接、机构上传等方式，实时归集全链条价格数据，打破信息孤岛。"两翼"即双向服务功能：一方 面为群众服务，让群众直观查询各定点机构药品、耗材、服务项目价格，实现"价比三家"；另一方面为 医保决策服务，将药店价格纳入协议管理，对价格畸形过高的解除协议 ...

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 National Healthcare Security Administration announced that by the end of 2024, the cumulative balance of the medical insurance fund will reach 3.86 trillion yuan [1] - A comprehensive regulatory system for the fund has been established, which includes proactive education, real-time reminders, post-event supervision, and regular inspections [1] - A total of 104.5 billion yuan has been recovered from the medical insurance fund through these regulatory measures [1]

Core Insights - Yantai's Medical Insurance Bureau has focused on the management of outpatient chronic special diseases, enhancing efficiency in medical insurance governance and fund utilization through standardized and intelligent approaches [1][5] Group 1: Financial Performance - Total expenses for outpatient chronic special diseases increased by 5.5% year-on-year, while total reimbursements rose by 3.9% [1] - Per capita expenses decreased by 2.4%, and average expenses per visit dropped by 8.3% [1] Group 2: Admission Management and Qualification Standards - The disease catalog for outpatient chronic special diseases and separately paid diseases consists of 82 types, with no new self-owned diseases to be recognized after 2025 [2] - The application process for qualification has been streamlined, allowing patients to apply for recognition at medical institutions and through the "Love Shandong" app, achieving a "zero-run" experience for patients [2] - A strict review process for qualification has been established, including regular expert audits and a mechanism for exiting patients who do not meet the cost threshold [2] Group 3: Information Technology and Cost Control - A drug cost control system for outpatient chronic special diseases has been implemented, linking drug usage directly to individual medical insurance settlements [3] - Regular analysis reports on outpatient chronic special disease expenses are compiled, and quarterly meetings are held to discuss cost control issues [3] - Training sessions are conducted for grassroots medical institutions to enhance awareness of cost control [3] Group 4: Quality Development of Medical Institutions - The first chronic disease health management center has been established in Yantai, integrating various services for chronic disease management [4] - A clinical expert team has been formed to develop treatment plans and ensure standardized management across hospitals [4] - Regulations for drug management have been established, promoting the use of domestic and collective procurement drugs while embedding management rules into prescription systems [4] Group 5: Future Outlook - Yantai will continue to optimize its management model for outpatient chronic special diseases, exploring innovative reforms in the medical insurance sector to enhance service quality and efficiency [5]