In order to strengthen the construction of the intelligent audit and monitoring knowledge base and rule base (hereinafter referred to as the "two bases") for medical security funds, improve regulatory efficiency, and promote the safe, efficient, and reasonable use of funds, the National Medical Security Administration announced today (15th) the "Intelligent Audit and Monitoring Knowledge Base and Rule Base Framework System for Medical Security Funds (Version 1.0)".
In addition to post event accountability and disciplinary punishment, the supervision of medical insurance funds also actively promotes intelligent auditing and monitoring. The medical insurance department moves the fund supervision checkpoint forward through advance reminders, in-process warnings, and post audit intelligent supervision systems, automatically intercepting "clear violations" and prompting "suspicious" behaviors that violate fair use rules. This requires a knowledge base and rule base as the basis for judgment.
In the framework system version 1.0 of the national "two databases", the knowledge base includes three categories of knowledge catalogs: policy, management, and medical, including legal regulations and policy norms, medical insurance information business codes, medical knowledge, management norms, and other content. The rule base is divided into policy categories (30 rules), management categories (28 rules), and medical categories (21 rules), including a total of 79 rules. According to the requirements of the "Two Banks" Management Measures, the National Medical Security Administration publicly releases the framework content of the "Two Banks" to the society, and medical security agencies use the "Two Banks" to carry out business management activities such as payment review, agreement assessment, and verification audit of medical insurance fee settlement; The medical security administrative department and institutions engaged in medical insurance administrative law enforcement use the "two repositories" to assist in carrying out medical insurance administrative supervision and administrative law enforcement related activities; Encourage designated pharmaceutical institutions to apply the "two libraries" to strengthen internal management and standardize pharmaceutical service behavior.
The national medical insurance "two libraries" grant full autonomy to local medical insurance departments
The "two databases" are the core of intelligent auditing and monitoring, and their quality directly affects the application effectiveness of the intelligent supervision subsystem. Before the launch of the national medical insurance information platform, the number of self built intelligent monitoring rules in various regions ranged from dozens to hundreds, and the number of knowledge varied from tens of thousands to millions, with varying complexity and simplicity. Some places had issues such as insufficient authority and practicality of the "two databases", which was not conducive to the further effectiveness of intelligent auditing and monitoring.
At the national level, we will strengthen the standardization of rule formulation and the management of the rule system, grant sufficient autonomy to local medical insurance departments, and independently set parameters, indicators, thresholds, application scenarios, etc. based on the framework of the national "two databases" system and local actual supplementary rules and knowledge. Under the framework of national rules, medical insurance departments in various regions fully solicit opinions from medical institutions, and set parameters, indicators, thresholds, and application scenarios for rules based on local medical insurance policies and fund regulatory objectives. Gradually and dynamically improve the rules for online use to ensure orderly and smooth operation. In practical applications, further verify the scientificity, rationality, and effectiveness of rules, and timely evaluate and adjust them. Encourage designated pharmaceutical institutions, industry associations, etc. to actively propose knowledge information or corresponding rules that meet the requirements of national policies and normative standards and have universal significance. Medical security administrative departments at all levels can include them in the scope of the "two databases" according to the prescribed procedures.
Suggestions on Respecting the Opinions of Medical Institutions in the Construction of the "Two Libraries"
The framework system version 1.0 emphasizes the relationship between following medical laws and appropriate and reasonable interventions in the construction of the "two libraries". The "two databases" rule includes policy, management, and medical rules. The operational logic, regulatory objectives, and effectiveness intensity of different rules vary. Strengthen supervision and intervention in illegal and irregular medical practices; For rules related to medical rationality, local medical insurance departments should fully listen to the opinions and suggestions of medical institutions when demonstrating and applying them. Specifically, among the 79 rules, the result of violating policy limiting rules is "clear violation", achieving automatic interception of illegal and irregular behaviors; Violation of fair use rules often results in "suspicious" results, and it is necessary to fully listen to the appeal opinions of medical institutions before determining whether to pay. Medical insurance departments at all levels should establish and improve management mechanisms, develop procedures for handling suspicious information, strengthen communication with medical institutions, and handle appeals and opinions from medical institutions well.
Intelligent supervision does not affect the normal medical treatment of insured individuals
Overall, the medical insurance department strengthens the supervision of medical insurance funds through intelligent regulatory means, with the fundamental purpose of protecting the people's "medical money" and "life-saving money", and fundamentally safeguarding the right of insured persons to seek medical treatment. On the one hand, insured individuals need to undergo identity recognition when seeking medical treatment, strictly implementing the real name medical treatment and drug purchase system to ensure that their ID matches. However, the identity recognition process is "insensitive" to insured individuals and will not affect their normal medical treatment behavior. On the other hand, the intelligent regulatory system regulates the diagnosis and treatment behavior of designated medical institutions through the operation of rules, providing real-time reminders to medical personnel for unreasonable diagnosis, examination, and prescription behavior, guiding them to consciously comply with clinical diagnosis and treatment standards and medical insurance management policies, carry out medical services in accordance with laws, regulations, and reasonable standards, ensure the safe, efficient, and reasonable use of medical insurance funds, and protect the rights and interests of insured persons to enjoy standardized medical services.
