Irregularities In Xuzhou City Basic Medical Insurance Processing And Reporting Incentives

Original Language Title: 徐州市基本医疗保险违规行为处理和举报奖励办法

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Irregularities in Xuzhou city basic medical insurance processing and reporting incentives

    (May 29, 2010, Xuzhou city people's Government at the 32nd Executive meeting on June 1, 2010 122th in Xuzhou city people's Government promulgated as of July 1, 2010) first in order to guarantee the security of the basic medical insurance fund, protect the legitimate rights and interests of insured, in accordance with the People's Republic of China administrative penalty provisions of the Act and other relevant laws and regulations, combined with the city's actual, these measures are formulated.

    Article within the administrative area of the city for violations of the provisions of the basic medical insurance system and reporting reward application of this approach.

    The basic medical insurance system in these measures, including basic medical insurance system for urban workers basic medical insurance system for urban residents.

    Article city and County (City) departments are responsible for the co-ordination of basic medical insurance medical insurance management.

    Health, financial, pricing, food and drug supervision, audit and other administrative departments in accordance with their respective responsibilities, to coordinate the implementation of these measures.

    Department of basic medical insurance medical insurance agency may be entrusted to designated medical institutions, appointed retail drugstores (hereinafter referred to as fixed-point units) to oversee and inspect the implementation of basic medical insurance service, to investigate the acts that violate the provisions of basic medical insurance and handling.

    Article fourth of units participating in basic medical insurance (hereinafter insured units) of any of the following acts, recovery of the illegal expenditure of basic medical insurance funds and insurance fined units of less than 500 Yuan and 30,000 yuan, directly responsible for the executives and other people in charge shall be fined not more than RMB 500 Yuan more than 2000:

    (A) proof of forgery, giving false evidence or false, heavy medical expenses;

    (B) deliberately not labour relations with this unit completely lost or most disabling illness of personnel to new labor relations by participating in medical insurance for urban workers, obtaining health insurance benefits;

    (Iii) other serious violations of the provisions of the health insurance act.

    Five basic medical insurance service (hereinafter referred to as insured persons) and other personnel of any of the following acts, recover the illegal expenditure of basic medical insurance fund, fined 500 Yuan more than 2000 Yuan the following fines:

    (A) counterfeiting or fraudulent use of others ' basic medical insurance certificate for medical treatment, purchase of medicines, basic medical insurance certificate or lent, transferred to another hospital, purchase of medicines;

    (B) forgery, alteration, damage, medical instruments, notes and other fraudulent funds of basic medical insurance;

    (C) conspire with fixed-point units or other persons, to medicine medicine, medicine or get cash fraudulently, such as basic medical insurance funds;

    (D) staff over the dispensing of insured, obviously exceeded demand for medical treatment, and involves a large amount;

    (E) loss of insured persons access to health insurance benefits after qualification, their family members or associated persons without required notice units, communities and health care insurance agencies, or provide false qualification materials, in the name of the insured person continues to enjoy medical insurance benefits in obtaining basic medical insurance funds;

    (F) refuses to cooperate with inspection, supervision and inspection process refused to provide or deliberately destroyed medical instruments and other materials;

    (VII) other serious violations of the basic provisions of the health insurance act.

    Insured persons, violation of the provisions of the preceding paragraph the circumstances are serious, to suspend the use of basic medical insurance card for six months to a year, converted to cash settlement-related medical costs reimbursed by the health insurance agencies after the audit in accordance with the regulations. Sixth fixed-point units and their staff with the following acts, in addition to recovery of illegal expenditure of basic medical insurance fund, shall, in accordance with medical care insurance agency agreements with them.

    In serious cases, fined 10,000 yuan and 30,000 yuan fine, its legal representative (Chief) and directly responsible were fined 500 Yuan more than 2000 Yuan fines; the circumstances are especially serious, cancel its point qualification, and will not be accepted within two years of their targeted qualification to apply for:

    (A) network without authorization and settlement-related medical claims costs;

    (B) knew or should have known the insured persons use, forging, altering the basic medical insurance, prescription or not in accordance with medical certificate of insurance project issue prescriptions given or treatment;

    (C) the means of credit card, credit card cash back after paying personal basic medical insurance fund or provide facilities for individuals obtaining basic medical insurance fund;

    (D) forge outpatient, inpatient, deception, swindle of basic medical insurance funds;

    (V) does not check medical insurance medical certificates, fake medical hospital, front (bed) hospital; or outside the scope of the provisions of basic medical insurance paid the cost included in the basic medical insurance fund;

    (Vi) to take drugs drugs, to drug or other improper means of acquiring the basic medical insurance fund;

    (VII) provision of false bills, rebate promotions by illegal means, of acquiring the basic medical insurance fund;

    (VIII) personnel for the treatment of insured or dispensing fees than non-insured persons, or swipe fees cost more than the cash settlement;

    (I) violation of the drug administration law and relevant provisions, and sale of counterfeit, fake and shoddy drugs;

    (J) the drug management, inventory accounting and inventory risked in kind;

    (11) the fixed-point units without authorization contract, lease or transfer to other units or individuals engaged in;

    (12) without a network of Sentinel units provide basic medical insurance or credit card;

    (13) refused to cooperate with inspection, supervision and inspection process refused to provide or deliberately destroyed medical instruments and related materials;

    (14) other serious violations of the basic provisions of the health insurance act.

    Article seventh non-fixed units and their staff of any of the following acts, in addition to recovery of illegal expenditure of basic medical insurance fund, fined 10,000 yuan and 30,000 yuan fine, its legal representative (Chief) and directly responsible were fined 500 Yuan more than 2000 Yuan fine, and will not be accepted within two years of their targeted qualification to apply for:

    (A) collection of basic medical insurance card for insured persons (card) to the designated credit card settlement-related costs;

    (B) network without authorization and settlement-related medical claims costs;

    (C) posing as fixed-point units provide credit card services to insured persons;

    (D) refuses to cooperate with inspection, supervision and inspection process refused to provide or deliberately destroyed medical instruments and related materials;

    (E) other serious violations of the basic provisions of the health insurance act.

    Eighth article of any units and individuals in obtaining basic medical insurance treatment or of obtaining basic medical insurance fund, by the Department of basic medical insurance for basic medical insurance fund ordered to refund fraud and fined not more than the amount defrauded more than 1 time times three times constitutes a crime, criminal responsibility shall be investigated according to law.

    Nineth health insurance agencies and their staff, one of the following acts, by the Department of basic medical insurance be ordered to rectify, make up for economic losses, the directly responsible and other persons directly responsible shall be given administrative sanctions:

    (A) does not provide basic medical insurance premiums into the insurance officer personal account and funds account;

    (B) unauthorized breaks or not complying with the provisions of the program cancellation insurance and basic medical insurance premiums paid by insured persons should be;

    (Iii) alter any basic medical insurance treatment standards or standards not complying with the provisions of the basic medical insurance fund;

    (D) conspire with insured persons or fixed-point units, obtaining of basic medical insurance funds;

    (E) due to dereliction of duty or violation of discipline resulting in loss of basic medical insurance funds;

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

    Article medical insurance authority and other relevant administrative departments of personnel who abuse their powers, neglect their duties, engage, by their work units or by the competent authorities, supervisory organs shall be subject to the administrative responsibility constitutes a crime, criminal responsibility shall be investigated according to law.

    11th medical insurance authorities may entrust a qualified social agencies conduct investigations of violations of the provisions of basic medical insurance.

    12th to encourage units and individuals to report violations of the provisions of basic medical insurance.

    Provide clues to the report is true and is not authority to master, and administrates the units or individuals provide major clues and evidence of an offence, by the Department of basic medical insurance in accordance with the relevant provisions of awards and its secrecy.

    Advocacy, reporting on informants, should ask the informer's consent.

    13th report accepts the specific requirements and conditions for reporting award should have, in accordance with the relevant provisions of the State, province.

    14th award criteria for the check report concerning breach expenditures recovered the amount of 10% to 20%, up to no more than 50,000 yuan reward standard of less than 100 yuan per 100 Yuan reward.

    Report content does not involve amounts or the amount cannot be determined, verified, granting the reward of 100 Yuan to 500 Yuan.

    15th report shall reward decision within six months from the date of issue, with the award decision and valid ID receive a bonus; has not received more than six months, considered giving up.

    16th report sources of bounty:

    (A) in accordance with the provisions of the assessment award funds;

    (B) the fixed-point units after the year-end accounts check deposit balances of funds;

    (C) other funds for rewards. Basic medical insurance report to the competent authority shall, in conjunction with the Ministry of finance to establish a sound award approving, issuing, receiving and other management systems.

    Reporting incentives should build separate accounts and separate management shall comply with financial regulations, financial accounting systems and financial discipline, and accept supervision by the financial and auditing departments and check.

    Article 17th of malicious reporting, making illegal acts shall be held in accordance with the relevant provisions of an informer's responsibility.

    18th for violation of medical assistance, supplementary medical insurance, work injury insurance and maternity insurance, retired medical personnel and manpower and six more than medical insurance for disabled soldiers and other acts, in accordance with the measures implemented. 19th article this way come into force on July 1, 2010.