The state medical security administration printed and distributed the measures for the management of knowledge base and rule base for intelligent audit and monitoring of medical security funds (for Trial Implementation)
2022-04-12
In order to further improve the supervision system of medical security fund, strengthen the management of knowledge base and rule base of intelligent audit and monitoring of medical security fund (hereinafter referred to as "two bases"), improve the supervision efficiency and promote the effective use of the fund, the State Medical Security Administration recently issued the measures for the management of knowledge base and rule base of intelligent audit and monitoring of medical security fund (Trial) (hereinafter referred to as the measures), which shall come into force from the date of promulgation. Intelligent audit and monitoring of medical insurance fund is an important technical means of medical insurance management in the information age. The construction of "two libraries" is the core of intelligent audit and monitoring, and its construction quality is related to the application effectiveness of intelligent audit and monitoring. As a whole, the measures focus on the construction and management of the "two repositories", focus on the construction of standardization and informatization, adhere to openness and transparency, and improve the authority, standardization and practicability of the "two repositories". The main features are as follows: First, clarify the functional positioning of "two libraries". Make it clear that medical security agencies use "two banks" to carry out handling business management activities such as advance reminder, payment review, agreement assessment and audit of medical insurance expense settlement; Medical security administrative departments and institutions engaged in medical insurance administrative law enforcement use the "two libraries" to assist in medical insurance administrative supervision and administrative law enforcement related activities; Encourage designated medical institutions to use "two libraries" to strengthen internal management and standardize medical service behavior. Second, clarify the basic principles and the responsibilities of medical insurance departments at all levels. It is clear that the construction and management of "two repositories" should follow the principles of science and rationality, multi-party consultation, openness, transparency and dynamic improvement. Clarify that the National Bureau is responsible for formulating the norms and standards for the construction and management of the "two warehouses", and formulate and publish the "two warehouses" framework system; The administrative departments of medical security at the provincial, prefecture and municipal levels are responsible for promoting the synchronous updating and localized application of the "two databases", and can supplement localized knowledge and rules as required. The third is to clarify the basic definition, relationship, basis source and construction procedure of "two repositories". It is clear that the rule base is generated based on the knowledge base and must be based on the corresponding knowledge. The construction of "two repositories" should go through the procedures of knowledge collection, rule compilation, multi-party demonstration, review and release, so as to ensure that the construction procedures of "two repositories" are fair and just, the content is scientific and reasonable, achieve multi-party consensus and highlight practicability. Fourth, clarify the dynamic adjustment procedures and requirements of "two libraries". Dynamic adjustment includes annual adjustment and immediate adjustment. In principle, annual adjustment shall be organized once a year. The annual adjustment shall be based on the construction and operation of the "two warehouses" in the previous year, and the opinions shall be widely solicited and the adjustment plan shall be made before the adjustment. In case of any situation affecting the applicability and effectiveness of the "two libraries", the immediate adjustment procedure shall be started. Fifth, clarify the doubtful point information processing procedures, operation monitoring and evaluation and data security requirements. The procedures for handling doubtful information shall include preliminary review, reexamination, appeal of supervision objects, investigation and verification, violation handling, etc. Medical security departments at all levels are required to strengthen the collection, classification and analysis of feedback information from regulatory objects, and carry out daily monitoring and annual evaluation on the operation stability and effectiveness of the "two libraries". Relevant participants shall strictly standardize data management and application to ensure data and information security. With regard to promoting intelligent audit and monitoring, the National Medical Insurance Bureau said that it would speed up sorting out the contents of the "two libraries", further optimize the framework structure of the "two libraries", fully carry out the demonstration of all parties, release the first batch of national unified "two libraries" after extensive consultation, comprehensively promote the intelligent audit and monitoring of medical security funds in combination with the deployment of handling audit and administrative supervision, introduce big data analysis technology, and continuously adjust Constantly optimize and enrich the monitoring rules through improvement and innovation, strive to improve the use value of the monitoring rules, and promote the application and effectiveness of intelligent audit and monitoring of medical security fund. (outlook new era)
Edit：Yuanqi Tang Responsible editor：Xiao Yu
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