医保基金监管进一步细化，将针对医护人员个人

近年来，医保基金监管取得了显著进展，建立健全了医保基金监管制度和执法体系，并通过大数据和人工智能技术，进行实时动态监控，构建起全环节的基金安全防控机制。常态化的飞行检查加强了对定点医药机构的监管和处理，严厉打击了欺诈骗保行为。然而，传统的医保基金监管手段只能处罚医疗机构，无法直接对违规的个人采取限制，违规人员能够轻易转移阵地，在不同的医疗机构流窜作案而不受制裁。这不仅令医保基金遭受损失，医疗机构也面临声誉下降的风险，而且对于其他遵纪守法的从业者来说也有失公平。

为了有效针对这一问题，国家医保局出台了《建立定点医药机构相关人员医保支付资格管理制度的指导意见》，明确要求将定点医药机构及定点零售药店涉及医保基金使用的相关人员纳入医保监管范围，提出对违规责任人进行记分管理，让违规者付出应有的代价，有效遏制医保基金滥用现象。这一新政弥补了监管制度中针对违规个人执法的缺失，指导意见提出的要求将于三年之内逐步落地实施。

纳入医保监管范围的相关人员分为两类：第一类是医院的相关人员，包括提供医疗护理服务的相关卫生专业技术人员，以及负责医疗费用和医保结算审核的相关工作人员。第二类是定点零售药店的主要负责人，即药品经营许可证上的主要负责人。医保监管过程中发现违法违规行为时，将根据严重程度对相关人员进行记分处理：相对较轻的记1-3分，重一点的记4-6分，更严重的记7-9分，最严重的欺诈骗保等行为记10-12分。

一年内累计记分达到9分的相关人员将被取消医保支付资格1-6个月，医保部门将暂停结算这段时间内相关人员提供医疗服务而产生的医保费用。累计记分达到12分的违法违规人员将被取消医保支付资格，并且需等待至少1年的时间才能够再次进行医保登记备案，恢复医保支付资格。如果违法违规情节十分严重，一次性记满12分，则需等待3年时间才能再次申请医保支付资格。

为防止违法违规人员更换医疗机构流窜作案，指导意见规定记分制度进行全国联网联动，违法违规人员的记分信息将进行跨机构、跨区域共享。此外，指导意见还要求建立异议申诉渠道，支持医疗机构和相关人员对记分处罚做出陈述、申辩，明确答复、修正时限，依法维护相关责任人员合法权益。

虽然记分规则按照严重程度进行了分级，然而每一级记分的情形还有待进一步细化。记分规则规定了对违法违规行为负一般、重要和主要责任进行不同程度的记分，而一般、重要和主要责任的认定也有待具体化。此外，医保基金监管和执法除了通过发现违法违规后进行追责外，还需从源头规范诊疗和收费行为，提高医护人员对法律法规的认识和理解，将违法违规行为扼杀在摇篮之中。

In recent years, significant progress has been made in the supervision of basic medical insurance (BMI) funds. A systematic supervision and enforcement system has been established and continuously improved. Leveraging Big Data and Artificial Intelligence, real-time dynamic monitoring of BMI funds has strengthened oversight. Additionally, regular unannounced inspections have effectively targeted BMI fraud and other illicit activities. 

However, traditional BMI supervision only targets medical institutions but cannot directly punish individuals. As a result, violators can easily relocate to other facilities and continue their misconduct. Apart from causing financial losses for BMI funds and reputational damage to medical institutions, this law enforcement loophole could also unfairly disadvantage law-abiding practitioners.

To effectively address this problem, the National Healthcare Security Administration (NHSA) issued the Guiding Opinions on Establishing a BMI Payment Qualification Management System for Personnel in Designated Medical Institutions. This document stipulates that not only designated medical institutions and retail pharmacies but also personnel managing BMI funds at these facilities will be supervised. The Guiding Opinions proposes a “point system” for individual violators, similar to traffic demerit points, with penalties varying according to their accumulated violations. It will be gradually implemented over the next three years.

Two categories of violators will be considered under BMI supervision and inspections. The first category comprises relevant personnel in hospitals, such as medical doctors and administrative staff responsible for reviewing medical expenses and BMI payment settlements. The second category includes the principal person in charge of designated retail pharmacies. When illicit behaviours are identified, accused individuals will receive demerit points based on the severity of their misconduct, ranging from one to three points for minor violations to ten to twelve points for the most severe fraud.

If an individual accumulates nine points in a calendar year, they will be disqualified from providing BMI-reimbursed services for one to six months, and unsettled expenses most likely need to be covered by the hospitals or healthcare personnel themselves. If a person reaches 12 points, they must wait at least one year before reapplying for qualification. Accumulating 12 points from a single law enforcement action will extend the disqualification period to three years.

To prevent violators from evading law enforcement by relocating, the Guiding Opinions stipulates that their records will be shared in real time across medical institutions and regions via the online system. It also mandates the establishment of an appeal system to protect the legitimate rights and interests of medical institutions and personnel under scrutiny.

While demerit points are assigned based on the severity of misconduct, the criteria for each level of severity need further refinement. Moreover, where different points are assigned to individuals based on whether they bear “general, major and primary responsibility for illicit conduct,” the definitions of these levels also need further specification. Finally, alongside penalising violations, BMI authorities should focus on improving healthcare practitioners’ understanding of regulations to prevent fraud and misconduct.