Fuzhou City Basic Medical Insurance Illegal Investigation Methods

Original Language Title: 福州市基本医疗保险违法行为查处办法

Read the untranslated law here: http://www.chinalaw.gov.cn/article/fgkd/xfg/dfzfgz/201308/20130800390307.shtml

Fuzhou City basic medical insurance illegal investigation methods

    (June 10, 2013, Fuzhou City people's Government, the 57th release as of August 1, 2013) first in order to prevent and investigate acts that violate the provisions of the basic medical insurance system, guarantee the security of basic medical insurance fund, according to the People's Republic of China Law on social insurance, the regulations on labor security supervision and other laws and regulations, combined with the city's actual, these measures are formulated. Article referred to basic medical insurance including workers ' basic medical insurance, basic medical insurance for urban residents, the new rural cooperative medical system.

    Basic medical insurance fund, administered by the workers ' basic medical insurance fund, urban resident basic medical insurance fund, consisting of new-style rural cooperative medical care funds.

    Investigation of violations within the administrative area of the city basic medical insurance procedures apply.

    Article, health human resources and social security administrative departments (hereinafter "basic medical insurance Department") according to the supervision and management of basic medical insurance the following Division of responsibilities: (A) the municipal human resources and social security administrative departments responsible for the administrative area of the city employees ' medical insurance, supervision and management of basic medical insurance for urban residents.

    Counties (cities), the Mawei district within human resources and social security administrative departments in charge of the regional workers ' basic medical insurance, supervision and management of basic medical insurance for urban residents. (B) of the municipal public health Administrative Department is responsible for the administrative area of the city of new rural cooperative medical supervision.

    Counties (cities), cangshan district, and Jinan district, Mawei district is responsible for the supervision and management of new-style rural cooperative medical care in the region.

    Home, finances, food and drug, agriculture, Commerce, price and other administrative departments should cooperate closely, in accordance with their respective responsibilities, to do the implementation of these measures. Article basic medical insurance agencies at all levels are responsible for the basic medical insurance system in the region of day-to-day management and audit activities.

    Basic medical insurance agencies at all levels should work with designated medical institutions, appointed retail drugstores signed a health insurance site services agreement specification designated medical institutions, basic medical insurance service of appointed retail drugstores.

    Five basic medical insurance Department and basic medical insurance agencies in the implementation of regulatory, routine audit process, may take the following measures:

    (A) shall enter the employing units, medical institutions, appointed retail drugstores and other places to carry out investigation and inspection;

    (B) investigations, inquiries about personnel requiring investigation, inspection units and individuals provide documents associated with the investigation, inspection, and an explanation and instructions;

    (C) access to basic medical insurance-related personnel rosters, statements of account books, accounting, payroll and other materials;

    (D) records, recordings, videos, photographs or collect evidence such as copies of materials;

    (E) other measures that could be taken in accordance with law.

    Sixth, the employing unit shall, in accordance with the People's Republic of China Law on social insurance and the interim regulations on the collection and payment of social security and the measures for the collection and payment of social security provisions, Fujian province, in time for the basic medical insurance for employees of the unit, and to pay basic medical insurance premiums.

    Seventh an employer shall not issue false labor relations, financial and accounting reports and other evidence, as does not meet the criteria of people participating in basic medical insurance or facilitate obtaining basic health insurance benefits.

    Eighth insurance (a) officers shall not be any of the following acts:

    (A) will my social security card (transfer) of others;

    (B) forged social security card social security card fake medical treatment or others;

    (C) the forged or altered files and other materials that escape the basic medical insurance payment obligations;

    (D) forging or altering medical instruments, medical bills, and basic medical insurance-related materials;

    (V) sold by the basic medical insurance costs of drug, medical device, medical materials, or diagnosis and treatment projects;

    (Vi) agencies colluded with the point of basic medical insurance service, the case of Medicare, air brush your social security card;

    (VII) health insurance conditions change or loss of access to basic medical insurance treatment eligibility, medical insurance agency is not required to go through the relevant change, cancellation procedures;

    (VIII) other acts that violate the provisions of the basic medical insurance system.

    The insured (a) personnel sustained injuries, traffic accidents and other cases for medical expenses should be paid by a third party, third party payment of medical expenses within 60 days after the funds of basic medical insurance should be first advance of medical expenses refunded. The Nineth designated medical institutions, designated retail pharmacy shall, in accordance with the designated provisions of the service agreement of medical insurance, established to meet the basic requirements of information management system of medical insurance system and on the diagnosis and treatment of items, medicines, medical equipment, implementation of information management, in accordance with the requirements of basic medical insurance agencies save, transmit information.

    Appointed medical institution when meeting patients should check towards the personnel of social security card, confirm social security card information with the cardholder agreement, in accordance with prescribed regulations prescribed and conditions recorded in the medical record.

    Tenth designated medical institutions shall not be any of the following acts:

    (A) the insured (a) repeated registration, duplicate or no indications for testing, inspection, treatment, factoring, or no indication in hospital or in other ways, providing necessary medical services and costs covered by basic medical insurance costs;

    (B) non-hospital personnel or hanging beds medical hospital personnel included in the basic medical insurance for hospitalization Fund settlement;

    (C) that does not belong to the scope of basic medical insurance fund, medicines, medical items, medical equipment, household goods, health products, such as cost, or out-of-Pocket medical expenses should be included in the basic medical insurance fund settlement;

    (D) violation of basic medical insurance treatment or use varieties requiring, with indications of excessive drug use, repeated drug use, illegal use of drugs, or to break down, to change the prescription or any other means, for the insured (a) staff dispense basic medical insurance costs;

    (E) violation of the provisions of the basic medical insurance system for basic medical insurance fee settlement payments;

    (Vi) forging or altering medical instruments or provide false medical expenses settlement voucher, cheat or assist others to obtain basic medical insurance fund expenditures;

    (VII) non-designated medical institutions for the settlement costs;

    (VIII) other acts that violate the provisions of the basic medical insurance system.

    11th designated retail pharmacies may not be any of the following acts:

    (A) to assist in basic medical insurance funds or supplies covered by basic medical insurance fund for settlement;

    (B) for the non-appointed retail drugstores and settlement costs;

    (C) other acts that violate the provisions of the basic medical insurance system.

    12th basic medical insurance agencies and their staff shall not be any of the following acts:

    (A) the violation to units or individuals register with the insurance of insured;

    (B) unauthorized breaks or not in accordance with the regulations unit and program cancellation insurance (a) personnel should be paid by basic medical insurance premiums;

    (C) alter the basic medical insurance payment standards or standards not complying with the provisions of the basic medical insurance fund;

    (D) used his position and work to facilitate assistance to the insurance unit, fixed-point units or individuals to defraud the urban basic medical insurance fund;

    (E) disclose employer or insurance (a) personal information;

    (Vi) other acts that violate the basic medical insurance provided by laws and regulations.

    13th and obstruct denied basic medical insurance authorities or basic health insurance body fifth inspection audit the implementation of these measures, by the Department of basic medical insurance for fined 500 Yuan more than 1000 Yuan fine.

    14th article violation this approach seventh article, and eighth article, and Nineth article, and tenth article, and 11th article provides one of, cheat basic medical insurance fund spending of, by basic medical insurance competent sector ordered returned cheat of basic medical insurance fund spending, sentenced cheat amount twice times above five times times following of fine; not cheat have basic medical insurance fund spending of, by basic medical insurance competent sector sentenced 1000 Yuan fine.

    Violation this approach Nineth article, and tenth article, and 11th article provides one of of, basic medical insurance handling institutions can on related Sentinel medical institutions, and Sentinel retail pharmacy, and Medicare Physician suspended Medicare settlement 1-12 months; plot serious of, basic medical insurance handling institutions should lifted with signed of medical insurance Sentinel service agreement, basic medical insurance competent sector should canceled its Sentinel medical institutions, and Sentinel retail pharmacy qualification.

    15th medical insurance (a) officers were suspected to have breached the provisions of article eighth, during the investigation period, basic medical insurance agencies can change their medical insurance costs.

    Designated medical institutions, designated retail pharmacies suspected of violating these rules the tenth, 11th article, during the period of investigation, costs of basic medical insurance agency may suspend payment.

    16th article basic medical insurance handling institutions or its staff violation this approach 12th article provides of, by basic medical insurance competent sector ordered deadline corrected, on directly is responsible for of competent personnel and other directly responsibility personnel law give disposition; caused basic medical insurance fund loss of, ordered recovered should paid of basic medical premium or recovered has paid of basic medical insurance fund; to employing units, and Sentinel medical institutions, and Sentinel retail pharmacy, and parameter insurance (collection) personnel caused loss of, law bear compensation responsibility.

    17th daily audits of basic medical insurance agency found in the appointed medical institutions, appointed retail drugstores, or acts that violate the norms of practice of its staff, it shall transfer the relevant administrative departments.

    Designated medical institutions, appointed retail drugstores, basic medical insurance insurance agencies or their staff, (a) obtaining funds of basic medical insurance for officials and expenses, if the circumstances are serious enough to constitute a crime, Department of basic medical insurance shall be transferred to the judicial organs in a timely manner, shall be investigated for criminal liability.

    18th is located outside the administrative area of the city, and the city basic medical insurance medical insurance agency signed a service agreement designated medical institutions, designated retail pharmacies in violation of the rules, basic medical insurance agency may suspend payment of medical care, and transfer to the seat of administration according to law. 19th to encourage units and individuals to report acts of violation of the provisions of the basic medical insurance system.

    Report is true and administrates the offered the main clues and evidence of unit or individual, Department of basic medical insurance and basic medical insurance agency shall be rewarded.

    20th daily audits of basic medical insurance agency found in urban and rural medical assistance outside of the basic medical insurance fund, former Medicaid and other basic medical insurance fund was defrauded, should be transferred to the relevant Fund Management Department. 21st article this way come into force on August 1, 2013.