State Council strengthens oversight of health insurance funds

The General Office of the State Council recently released a circular aimed at strengthening oversight of medical security funds.

Yan Qinghui, deputy director of the National Healthcare Security Administration, said that by the end of April, authorities had launched over 3.4 million inspections on medical institutions, handed out about 1.63 million penalties and retrieved misused funds worth 80.5 billion yuan ($11 billion).

Meanwhile, medical fraud cases have become harder to detect over the years and the rollout of reform measures, such as streamlining cross-provincial settlements services and trials of long-term care insurance programs, have posed fresh requirements for supervisors, he said during a news conference on Friday.

As part of efforts to ramp up supervision, the circular stressed that random inspections will be rolled out on a regular basis.

Jiang Chengjia, an official at the administration, said that local authorities have been required to draft annual plans on unannounced inspections while paying special attention to tips submitted by the public and those suggested by big data or smart monitoring systems, and to cases exposed by media.

Yan, the deputy director, said that a series of random inspections targeting high-value orthopedic consumables last year enabled supervisors to formulate methods and rules tailored to the sector, which have been applied to routine inspections nationwide this year.

Due to the massive number of medical institutions and a shortage of qualified supervisors, Yan added that smart surveillance systems have been deployed and helped recover 3.85 billion yuan.

Jiang said that the administration has continued to step up the role of big data in its supervision drives, such as expanding use of its anti-fraud big data model and integrating such online tools with on-site inspections.

For example, he said the administration has established a system that detects potential fraud by analyzing drug sales.

"Through the system, a hospital worker was found to withhold medical security accounts of patients to get prescriptions for self, and family members and relatives. The person is now being handled by local public security authorities," he said.