Driver’s license-style scoring- Relevant personnel of designated medical institutions who violate laws and regulations may be terminated from medical insurance payment qualifications
On the 27th, the National Healthcare Security Administration (NHSA) held a press conference to unveil the “Guiding Opinions on Establishing a Management System for Medical Insurance Payment Qualification of Personnel at Designated Medical Institutions.” This initiative broadens the scope of medical insurance regulation from institutions to the individuals involved, implementing a “license-style points tracking” system that aims to facilitate dynamic and precise management within the framework of medical insurance agreements.
During the conference, a representative from the NHSA explained that personnel who utilize medical insurance funds at designated institutions will obtain medical insurance payment qualifications upon signing service agreements with insurance agencies. This new system encompasses two primary categories:
1. Medical professionals working in hospitals, which includes those providing services to insured individuals—such as medical, nursing, and technical staff—as well as personnel responsible for reviewing medical expenses and insurance settlements.
2. Key personnel at designated retail pharmacies, specifically those identified as the primary responsible individuals on drug operating licenses.
Regarding penalties, any personnel who accumulate 12 points within a calendar year will lose their medical insurance payment qualification. The NHSA will closely monitor compliance, assigning points based on the severity of infractions: minor violations may incur 1-3 points, moderate violations 4-6 points, serious offenses 7-9 points, and the most severe infractions, including fraud, may lead to 10-12 points.
If an individual reaches 9 points in a year, their medical insurance payment qualification will be suspended for a period of 1-6 months, during which time costs incurred for services will not be reimbursed (except in emergencies). Those who hit 12 points will face termination of their qualification, with costs accrued during this period also going unpaid. Furthermore, individuals who accumulate 12 points will be prohibited from re-registering for a year after termination, or for three years if they hit that threshold in a single incident.
The points system will be integrated nationwide. If a medical professional’s insurance payment qualification is suspended or terminated at one institution, similar measures will be enforced at other designated institutions. Regional points penalties will be shared across the country, fostering cooperation among institutions and jurisdictions.
Highlighting the need for collaborative governance among medical insurance, healthcare, and pharmaceuticals, the NHSA representative emphasized that this management system will enhance oversight. The NHSA will relay information about points and penalties to health and drug regulatory bodies, enabling them to manage relevant personnel for a unified regulatory strategy.
To promote long-term compliance, the NHSA intends to create an individual medical insurance integrity record for the relevant personnel, linking them to a unique identity code that acts as a lifelong identifier within the national insurance system—similar to a social security number that remains unchanged regardless of relocation. This will help establish a comprehensive record of their adherence to medical insurance laws and regulations throughout their careers.
According to the NHSA representative, the implementation of this management system is a crucial step toward combating the misuse of medical insurance funds. Previously, the NHSA faced challenges in enforcing regulations at the individual level, allowing some individuals to commit fraudulent activities without facing consequences, often merely transitioning to new roles after infractions.
In 2023 alone, inspections of 500 designated medical institutions nationwide uncovered approximately 2.21 billion yuan in suspected violations. Notably, targeted inspections utilizing big data models identified 185 institutions with 810 million yuan in suspected violations, resulting in 111 confirmed cases of fraud.
Looking ahead, the NHSA aims to enhance its regulatory approach by focusing on systematic, holistic, and collaborative oversight while actively exploring innovative strategies to create a robust regulatory framework for the ongoing management of medical insurance funds. Despite increased scrutiny in recent years, violations among designated institutions continue to occur, underscoring the necessity for an approach that holds individuals accountable, ensuring fairness and compliance across the board.
