Just now! The National Health Insurance Board has issued an important document concerning medical de

Audit: audit is to examine and audit; verification is to audit and verify. The National Health Insurance Bureau will perform verification on a number of items for medical institutions, various enterprises and natural persons, involving areas such as the use and procurement of high-value consumables, which concern medical institutions and retail institutions at all levels. For the content of this document, experts in the industry have analysed Cyberland's equipment: the actual purchase and sale prices and quantities may be the direction of strict investigation, and the sales information and purchase of medicines from manufacturers, operators and medical institutions may be the key content.

The National Health Insurance Bureau in May this year released the "medical security development statistics snapshot", pointed out that the medical insurance departments at all levels of a total of 815,000 on-site inspection of designated medical institutions, investigating and dealing with illegal and non-compliant medical institutions 264,000, including the termination of medical insurance agreement 6730, administrative punishment 6638, transferred to judicial organs 357.

Although the results of this audit are unknown for the time being, it can be seen from the way the audit will be conducted that field visits will be used to investigate and collect evidence as a basis for forming audit conclusions; for individuals, smart devices such as biometric identification will be used to collect audit information or evidence ...... This may roll up a top-down wheeled inspection war.

Joint national audits

Today (September 6), the National Health Insurance Administration (NHA) released the "Notice of Public Consultation on the Interim Measures for the Management of Medical Security Audits (Draft for Comments)" (hereinafter referred to as the "Draft for Comments").

The purpose of the inspection is to ensure that medical institutions and retail pharmacies (hereinafter collectively referred to as "designated medical institutions") fulfil their medical insurance agreements, that participants enjoy their medical insurance benefits and that other units and individuals are involved in the use of medical insurance funds in accordance with the law.

Focus 1: Information on medical purchases and other information is included in the audit

Provincial-level agencies provide guidance to municipal and county-level agencies in their auditing work. The agencies at all levels should strengthen joint collaboration, exchange and share information, and implement verification of the same audited object in the same period should be carried out jointly to avoid duplication and multiple inspections.

The agencies should make full use of the medical insurance intelligent monitoring system to provide prior reminders, early warnings and post-surveillance, and include in the scope of audit the medical services provided by designated medical institutions and their staff, as well as the information on medical purchases by participants (including those who are insured in other places for medical treatment locally).

Focus 2: Checking the "incoming, outgoing and in-stock" data of medical consumables

Information and data required for the audit of medical insurance costs through the designated medical institutions, including but not limited to the list of medical insurance fund settlements, data on the "import, sale and storage" of medicines and medical consumables, etc.

Data and information on the fulfilment of medical insurance agreements and the use of medical insurance funds by designated medical institutions, including medical insurance fund settlement lists, data on the "import, sale and storage" of drugs and medical consumables, and prescriptions, medical records, treatment and examination records, cost details, accounting vouchers and financial accounts related to medical insurance fund settlement.

Information on the costs of medical services, drugs and medical consumables applied for payment by designated medical institutions to the agency.

Multi-modal joint audits

Network method: The handling agency obtains and monitors and analyses audit data information in real time from the medical security information system such as medical security settlement, payment and intelligent audit.

According to policy regulations, the analysis rules are dynamically adjusted in conjunction with payment reform, centralized quantity procurement, medical insurance catalogue adjustment, and changes in medical service violations. The medical insurance intelligent audit generates information on doubtful issues and, after manual review, can send doubtful data to designated medical institutions on a regular or irregular basis according to audit needs.

The designated medical institution verifies doubtful data, provides explanations and clarifications, evidential materials and timely feedback as required.

The auditor will fully discuss and analyse the feedback from the designated medical institutions and the supporting materials, and form an audit conclusion. After verification, if the suspected problem is true, it is confirmed as a problem; if the suspected problem is not true, the suspected problem is eliminated.

Audit conclusions are sent via the internet or in writing. If the suspected problem is true, an audit result notification letter is produced and the auditees are dealt with in accordance with the agreement.

When the auditor provides feedback and supporting materials to the audited object for verification and validation, the auditor may turn to the field audit or written audit process if it is necessary.

On-site approach: on-site audit at the designated medical institution and related sites.

When the field audit is carried out on the designated medical institutions, relevant units and personnel, the handling agency will investigate and collect evidence by reviewing and retrieving materials, inspecting the site and interviewing the relevant personnel as the basis for forming the audit conclusion. For individuals, audit information or evidence can be collected by smart devices such as biometric identification.

When the auditor inspects and copies the relevant information (financial accounts, personnel expenses, accounting vouchers, prescriptions, medical records, treatment and examination records, cost details, and records of medicines and medical consumables in and out of storage) of the audited object, the audited object shall cooperate and truthfully provide relevant materials and information.


When making copies of the relevant information of the audited subject, the legal representative of the audited subject (or the agent entrusted by the legal representative) shall, after confirming that the copied information is correct with the original, indicate on the copied information the source, number of pages, time of copying and the words "verified that this copy is consistent with the original", and sign or seal the copy.


If the designated medical institution does not have the working conditions to check and copy electronic and paper medical records on site, the auditor can transfer the relevant information and fill in the medical insurance audit transfer form, and after both parties have counted and checked, the auditor and the legal representative of the subject of the audit (or the agent entrusted by the legal representative) will sign or seal on the medical insurance audit transfer form.


Written method: According to the needs of the audit, the agency will request the designated medical institutions to report the purchase price and "purchase, sale and stock" data of drugs and medical consumables, the implementation of medical services and financial information, etc.; the designated retail pharmacies will be requested to report the "purchase, sale and stock" data of drugs and financial information, etc. The designated retail pharmacies are required to report the "purchase, sales and inventory" data and financial information of the drugs they operate. The designated pharmacies should be responsible for the authenticity and completeness of the materials provided.


Questioning methods: Understand the situation through face-to-face questioning with the subject of the audit and relevant personnel, ascertain the facts, form questioning records and fix evidence.