Huainan Fengtai: Strengthening the supervision of medical insurance physicians and standardizing the behavior of diagnosis and treatment

< p>In order to further standardize medical insurance services and strengthen the management of medical insurance funds, Fengtai County, Huainan City, with the help of annual medical insurance physician signings, has taken multiple measures to supervise medical insurance physicians, and promote the extension of medical insurance fund supervision to medical staff’s diagnosis and treatment behavior.

Strictly control the entrance and apply for the best. In light of the actual performance of licensed physicians or licensed assistant physicians, each designated medical institution will select qualified physicians to apply for a medical insurance physician agreement. The designated medical institutions shall, in accordance with the relevant requirements of the management measures, submit the relevant materials and lists of qualified physicians to the county medical insurance agency for recordation, and compile service codes if they pass the recordation review. Physicians whose service codes have been cancelled must participate in the medical insurance policy business training organized by the county medical insurance agency or the hospital where they belong, and apply for restoration of service codes after passing the review.

One person, one code, standardized management. Fengtai County’s 937 medical insurance physician services all implement “one person, one code”. The handling agency is responsible for evaluating the medical service behavior of medical insurance physicians, and providing policy training to the staff of the medical insurance management department of designated medical institutions or medical insurance physicians. Designated medical institutions shall formulate the management measures for their own medical insurance physicians, and regularly conduct medical insurance policy training for in-hospital medical insurance physicians, no less than twice a year; when there are relevant adjustments to medical insurance policies, training should be organized in a timely manner. Establish a medical insurance physician integrity evaluation system, record the evaluation, violation handling and other related situations, and enter the medical insurance physician file information database in a timely manner for inquiries by the medical security departments and designated medical institutions in other overall planning areas in the province.

Refine responsibilities and standardize diagnosis and treatment. Medical insurance physicians should carefully verify the relevant identity information of the insured persons during the treatment to ensure that the personal certificates are consistent to prevent the phenomenon of impersonation, hospitalization, etc.; Medical records should be objective, comprehensive, true, accurate, timely and complete; adhere to the principle of treating due to illness, rational inspection, rational treatment, and rational use of drugs. No over-prescription, no induction of over-medication, and no reduction in service quality. Adhere to the system of responsibility for the first diagnosis, implement the system of referrals at different levels, and must not shirk or reject patients, and must not use any excuse to let the insured be discharged early or late; when using drugs, diagnosis and treatment items and medical service facilities that are not included in the medical insurance catalog, you should Explain to the insured or their family members and obtain their consent, except for emergency, rescue and other special circumstances. Check the medical records of insured personnel, avoid repeated prescriptions and repeated inspections, and strictly implement relevant regulations such as taking medicines after discharge; assist the medical security department to do a good job in the publicity of medical security policies, and cooperate with the medical security department staff in the inspection.

Rewards and punishments are ordered and administered scientifically. In a calendar year, if the cumulative deduction of medical insurance physicians reaches 6 points, the handling agency shall conduct an interview with the medical insurance physician in conjunction with the designated medical institution; if the cumulative deduction of 9 to 11 points, the service agreement shall be suspended for 1 to 3 Monthly; if the cumulative deduction reaches 12 points or if the deduction points exceed 9 points for three consecutive years, the handling agency shall cancel the service agreement with the medical insurance doctor, and the handling agency will not accept the doctor to re-sign the agreement within one year from the date of the termination of the agreement. Application for service agreement; if 12 points are deducted at one time, depending on the severity of the circumstances, the handling agency shall not sign a medical insurance doctor agreement with it for 1 to 5 years from the date of termination of the agreement. Advocate and encourage designated medical institutions to link medical insurance physicians’ implementation of medical insurance policies, performance of service agreements, the quality of medical services provided, and the satisfaction of insured personnel with their annual assessments, wages, etc., and give full play to the reward and punishment system for medical services. Constrain the guiding role and enhance the awareness of independent cost control in designated medical institutions.