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异常数据引发飞行检查,国家医保局精准查处多起典型案例
Jing Ji Guan Cha Bao· 2025-09-30 02:03
(原标题:异常数据引发飞行检查,国家医保局精准查处多起典型案例) 经济观察网 据国家医保局官网信息,依托全国统一的医保信息平台,国家医保局精准查处多起异常数 据典型案例,做到发现一起、查处一起、整改一起,医保数据对监管的赋能作用持续凸显。 神秘未知医生大量开药 常规药品数据监测发现,某名医生开具烟酰胺总金额高于全国平均水平200余倍。异常数据引起医保部 门关注,迅速组织监管力量对相应医院医保结算数据作重点筛查,发现较多疑点数据,医保基金飞检组 随即入驻。 检查发现,烟酰胺开方量异常由"数据质量塌方"造成。该院上传的部分住院费用数据,开单医生处未填 写真实医生姓名,而是在数据处理中被填充为"未知"。数据上传国家医保信息平台后,该院多位"未 知"医生汇总的烟酰胺开方量触发异常报警,暴露定点医疗机构数据填报不规范和数据校验机制缺失的 叠加问题。 高龄老人开展辅助生殖 飞检组坚持实事求是,向被检医院及当地医保部门反馈数据问题并要求整改,未作处罚。对检查发现的 其他违法违规使用医保基金问题,依法依规作出处理。 日常数据监测发现,某医院为73岁老人开展"无痛取卵",另一医院则为86岁老人开展"试管内受精"。发 现问题后, ...
“十四五”时期医保基金累计支出超十二万亿元 减轻看病负担 加强基金监管(权威发布·高质量完成“十四五”规划)
Ren Min Ri Bao· 2025-07-24 22:27
Core Insights - The article discusses the significant advancements and reforms in China's medical insurance system during the "14th Five-Year Plan" period, emphasizing the focus on improving public health and reducing medical costs for citizens [1][2]. Group 1: Medical Insurance Coverage - By 2024, the number of people covered by basic medical insurance is expected to reach 1.327 billion, with a stable participation rate of around 95% during the "14th Five-Year Plan" [1][2]. - Nearly 20 billion medical insurance reimbursements are anticipated from 2021 to 2024, with 2024 figures projected to be 1.6 times that of 2020 [2]. Group 2: Support for Specific Demographics - As of June this year, 253 million people are enrolled in maternity insurance, with cumulative expenditures reaching 438.3 billion yuan, benefiting over 96.14 million instances [2]. - The long-term care insurance system is being established, with 190 million participants expected by the end of 2024, and over 95% of village clinics included in the insurance network [2]. Group 3: Healthcare Accessibility and Efficiency - The number of designated medical institutions for insurance has reached 1.1 million, and the direct settlement rate for cross-province hospitalizations is around 90% [3][5]. - The implementation of a unified national medical insurance information platform has improved service efficiency, with over 1.236 billion people using medical insurance codes for direct settlement [4][5]. Group 4: Fund Security and Regulation - The cumulative recovery of medical insurance funds has reached 104.5 billion yuan during the "14th Five-Year Plan," with a total fund balance of 3.86 trillion yuan expected by the end of 2024 [6][7]. - The National Medical Insurance Bureau has intensified supervision and regulation, conducting inspections on 335,000 medical institutions and recovering 16.13 billion yuan in funds in the first half of this year [6][7].