地方实践：基层医疗机构基金监管模式的探索与思考
<section powered-by="xiumi.us" style="margin: 0px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; color: rgb(34, 34, 34); font-family: -apple-system, BlinkMacSystemFont, Helvetica Neue, PingFang SC, Hiragino Sans GB, Microsoft YaHei UI, Microsoft YaHei, Arial, sans-serif; letter-spacing: 0.544px; text-align: justify; white-space: normal; background-color: rgb(255, 255, 255); visibility: visible; overflow-wrap: break-word !important;"><p style="margin-top: 0px; margin-bottom: 0px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; clear: both; min-height: 1em; visibility: visible; overflow-wrap: break-word !important;">随着基本医疗保险实现全覆盖，就医人次、频次大量增加，医疗机构欺诈骗保行为时有发生，违法犯罪的手段呈现隐蔽性、多样化趋势。枞阳县以建立医院医保管理制度、健全医保基金监管体制、完善基金监管约束机制为抓手，积极探索建立医保基金监督管理长效机制，规范定点医疗机构行为，促使其科学合理使用医保基金。<br style="margin: 0px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; overflow-wrap: break-word !important; visibility: visible;"/></p><p style="margin-top: 0px; margin-bottom: 0px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; clear: both; min-height: 1em; visibility: visible; overflow-wrap: break-word !important;"><br style="margin: 0px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; overflow-wrap: break-word !important; visibility: visible;"/></p></section><p></p><section powered-by="xiumi.us" style="margin: 0px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; color: rgb(34, 34, 34); font-family: -apple-system, BlinkMacSystemFont, Helvetica Neue, PingFang SC, Hiragino Sans GB, Microsoft YaHei UI, Microsoft YaHei, Arial, sans-serif; letter-spacing: 0.544px; text-align: justify; white-space: normal; background-color: rgb(255, 255, 255); visibility: visible; overflow-wrap: break-word !important;"><section style="margin: 0px 0px 10px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; overflow-wrap: break-word !important; text-align: center; justify-content: center; display: flex; flex-flow: row nowrap; visibility: visible;"><section style="margin: 0px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; overflow-wrap: break-word !important; display: inline-block; width: auto; vertical-align: top; line-height: 0; background-image: linear-gradient(rgb(165, 145, 186) 0%, rgb(141, 122, 186) 100%); min-width: 10%; flex: 0 0 auto; height: auto; align-self: flex-start; visibility: visible;"><section powered-by="xiumi.us" style="margin: 0px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; overflow-wrap: break-word !important; visibility: visible;"><section style="margin: 0px 0px 3px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; overflow-wrap: break-word !important; transform: translate3d(-3px, 0px, 0px); justify-content: center; display: flex; flex-flow: row nowrap; visibility: visible;"><section style="margin: 0px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; overflow-wrap: break-word !important; display: inline-block; width: 184.766px; vertical-align: top; background-color: rgba(255, 255, 255, 0.76); line-height: 2; border-bottom: 0px none rgb(62, 62, 62); border-bottom-right-radius: 15px; overflow: hidden; align-self: flex-start; flex: 0 0 auto; visibility: visible;"><section powered-by="xiumi.us" style="margin: 4px 0px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; overflow-wrap: break-word !important; transform: translate3d(4px, 0px, 0px); visibility: visible;"><section style="margin: 0px; padding: 0px 13px; outline: 0px; max-width: 100%; box-sizing: border-box; overflow-wrap: break-word !important; color: rgb(36, 30, 52); line-height: 1.8; letter-spacing: 1px; text-align: justify; visibility: visible;"><p style="margin-top: 0px; margin-bottom: 0px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; clear: both; min-height: 1em; visibility: visible; overflow-wrap: break-word !important;"><strong style="margin: 0px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; overflow-wrap: break-word !important; visibility: visible;">一、 主要做法和成效</strong></p></section></section></section></section></section></section></section></section><section powered-by="xiumi.us" style="margin: 0px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; color: rgb(34, 34, 34); font-family: -apple-system, BlinkMacSystemFont, Helvetica Neue, PingFang SC, Hiragino Sans GB, Microsoft YaHei UI, Microsoft YaHei, Arial, sans-serif; letter-spacing: 0.544px; text-align: justify; white-space: normal; background-color: rgb(255, 255, 255); visibility: visible; overflow-wrap: break-word !important;"><p style="margin-top: 0px; margin-bottom: 0px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; clear: both; min-height: 1em; visibility: visible; overflow-wrap: break-word !important;"><br style="margin: 0px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; overflow-wrap: break-word !important; visibility: visible;"/></p></section><section powered-by="xiumi.us" style="margin: 10px 0px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; color: rgb(34, 34, 34); font-family: -apple-system, BlinkMacSystemFont, Helvetica Neue, PingFang SC, Hiragino Sans GB, Microsoft YaHei UI, Microsoft YaHei, Arial, sans-serif; letter-spacing: 0.544px; white-space: normal; background-color: rgb(255, 255, 255); visibility: visible; overflow-wrap: break-word !important;"><section style="margin: 0px; padding: 0px 0px 0px 30px; outline: 0px; max-width: 100%; box-sizing: border-box; overflow-wrap: break-word !important; display: inline-block; min-width: 10%; vertical-align: top; visibility: visible;"><section powered-by="xiumi.us" style="margin: 0px 0px -30px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; overflow-wrap: break-word !important; transform: translate3d(-30px, 0px, 0px); visibility: visible;"><section style="margin: 0px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; overflow-wrap: break-word !important; display: inline-block; width: 30px; height: 30px; vertical-align: top; overflow: hidden; border-width: 0px; border-radius: 100%; border-style: none; border-color: rgba(118, 178, 124, 0); background-color: rgba(141, 122, 186, 0.3); visibility: visible;"><section powered-by="xiumi.us" style="margin: 0px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; overflow-wrap: break-word !important; text-align: justify; visibility: visible;"><p style="margin-top: 0px; margin-bottom: 0px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; clear: both; min-height: 1em; visibility: visible; overflow-wrap: break-word !important;"><br style="margin: 0px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; overflow-wrap: break-word !important; visibility: visible;"/></p></section></section></section><section powered-by="xiumi.us" style="margin: 0px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; overflow-wrap: break-word !important; transform: translate3d(-15px, 0px, 0px); visibility: visible;"><section style="margin: 0px; padding: 3px 0px; outline: 0px; max-width: 100%; box-sizing: border-box; overflow-wrap: break-word !important; display: inline-block; min-width: 10%; vertical-align: top; visibility: visible;"><section powered-by="xiumi.us" style="margin: 0px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; overflow-wrap: break-word !important; color: rgb(141, 122, 186); text-align: justify; visibility: visible;"><p style="margin-top: 0px; margin-bottom: 0px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; clear: both; min-height: 1em; visibility: visible; overflow-wrap: break-word !important;"><strong style="margin: 0px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; overflow-wrap: break-word !important; visibility: visible;">1.建立医院医保管理制度</strong></p></section></section></section></section></section><section powered-by="xiumi.us" style="margin: 0px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; color: rgb(34, 34, 34); font-family: -apple-system, BlinkMacSystemFont, Helvetica Neue, PingFang SC, Hiragino Sans GB, Microsoft YaHei UI, Microsoft YaHei, Arial, sans-serif; letter-spacing: 0.544px; text-align: justify; white-space: normal; background-color: rgb(255, 255, 255); visibility: visible; overflow-wrap: break-word !important;"><p style="margin-top: 0px; margin-bottom: 0px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; clear: both; min-height: 1em; visibility: visible; overflow-wrap: break-word !important;"><br style="margin: 0px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; overflow-wrap: break-word !important; visibility: visible;"/></p><p style="margin-top: 0px; margin-bottom: 0px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; clear: both; min-height: 1em; visibility: visible; overflow-wrap: break-word !important;">2019年枞阳县医疗保障局成立后，为推动医疗机构由被动接受医保基金监管，向主动参与医保基金管理转变，不断完善医院医保管理制度建设，推动基金监管关口前移。<strong style="margin: 0px; padding: 0px; outline: 0px; max-width: 100%; color: rgb(141, 122, 186); visibility: visible; box-sizing: border-box !important; overflow-wrap: break-word !important;">一是</strong>会<strong style="margin: 0px; padding: 0px; outline: 0px; max-width: 100%; color: rgb(141, 122, 186); visibility: visible; box-sizing: border-box !important; overflow-wrap: break-word !important;"></strong>同卫健部门出台了《关于加强定点医疗机构医保基金监管内部管理工作的通知》，在全县所有具备住院诊疗能力的医疗机构成立医保工作领导小组，并在各科室设置医保物价管理员，督促各科室医护人员规范诊疗、合理收费。<strong style="margin: 0px; padding: 0px; outline: 0px; max-width: 100%; color: rgb(141, 122, 186); visibility: visible; box-sizing: border-box !important; overflow-wrap: break-word !important;">二是</strong>强化医护人员医保政策和“一条例、两办法”培训，针对常见医保违规问题和医保违规典型案例，汇编成《枞阳县医疗保障基金检查指南》《“三个以案”警示教育医保系统案例选编》，印发到各定点医疗机构医护人员进行学习，指导基层医疗机构对医保违规行为进行事前防控。<strong style="margin: 0px; padding: 0px; outline: 0px; max-width: 100%; color: rgb(141, 122, 186); visibility: visible; box-sizing: border-box !important; overflow-wrap: break-word !important;">三是</strong>建立县域医共体医保基金监管派驻督导制度，向两个紧密型县域医共体牵头单位分别派驻了医保督导员，指导定点医疗机构健全内控管理制度；定期开展院内巡查，及时掌握定点医疗机构医保政策执行情况等；宣传医保法律法规、文件，确保医保决策、意见传达到医共体基层成员单位。</p><p style="margin-top: 0px; margin-bottom: 0px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; clear: both; min-height: 1em; overflow-wrap: break-word !important;"><br style="margin: 0px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; overflow-wrap: break-word !important;"/></p><p style="margin-top: 0px; margin-bottom: 0px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; clear: both; min-height: 1em; overflow-wrap: break-word !important;">制度建立以来，全县医疗机构的重复收费、超标准收费、过度检查、违规收取一性耗材费等10多个问题的医保违规支付金额从2018年的729.35万元下降到2021年的384.53万元。2021年各医疗机构自查医保违规支付基金17.66万元，全部主动退回基金专户。</p><p style="margin-top: 0px; margin-bottom: 0px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; clear: both; min-height: 1em; overflow-wrap: break-word !important;"><br style="margin: 0px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box !important; overflow-wrap: break-word !important;"/></p><p style="margin-top: 0px; margin-bottom: 0px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; clear: both; min-height: 1em; text-align: center; overflow-wrap: break-word !important;"></p><p style="margin-top: 0px; margin-bottom: 0px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; clear: both; min-height: 1em; overflow-wrap: break-word !important;"><br style="margin: 0px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box !important; overflow-wrap: break-word !important;"/></p></section><section powered-by="xiumi.us" style="margin: 10px 0px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; color: rgb(34, 34, 34); font-family: -apple-system, BlinkMacSystemFont, Helvetica Neue, PingFang SC, Hiragino Sans GB, Microsoft YaHei UI, Microsoft YaHei, Arial, sans-serif; letter-spacing: 0.544px; white-space: normal; background-color: rgb(255, 255, 255); overflow-wrap: break-word !important;"><section style="margin: 0px; padding: 0px 0px 0px 30px; outline: 0px; max-width: 100%; box-sizing: border-box; overflow-wrap: break-word !important; display: inline-block; min-width: 10%; vertical-align: top;"><section powered-by="xiumi.us" style="margin: 0px 0px -30px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; overflow-wrap: break-word !important; transform: translate3d(-30px, 0px, 0px);"><section style="margin: 0px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; overflow-wrap: break-word !important; display: inline-block; width: 30px; height: 30px; vertical-align: top; overflow: hidden; border-width: 0px; border-radius: 100%; border-style: none; border-color: rgba(118, 178, 124, 0); background-color: rgba(141, 122, 186, 0.3);"><section powered-by="xiumi.us" style="margin: 0px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; overflow-wrap: break-word !important; text-align: justify;"><p style="margin-top: 0px; margin-bottom: 0px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; clear: both; min-height: 1em; overflow-wrap: break-word !important;"><br style="margin: 0px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; overflow-wrap: break-word !important;"/></p></section></section></section><section powered-by="xiumi.us" style="margin: 0px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; overflow-wrap: break-word !important; transform: translate3d(-15px, 0px, 0px);"><section style="margin: 0px; padding: 3px 0px; outline: 0px; max-width: 100%; box-sizing: border-box; overflow-wrap: break-word !important; display: inline-block; min-width: 10%; vertical-align: top;"><section powered-by="xiumi.us" style="margin: 0px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; overflow-wrap: break-word !important; color: rgb(141, 122, 186); text-align: justify;"><p style="margin-top: 0px; margin-bottom: 0px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; clear: both; min-height: 1em; overflow-wrap: break-word !important;"><strong style="margin: 0px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; overflow-wrap: break-word !important;">2.健全医保基金监管机制</strong></p></section></section></section></section></section><section powered-by="xiumi.us" style="margin: 0px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; color: rgb(34, 34, 34); font-family: -apple-system, BlinkMacSystemFont, Helvetica Neue, PingFang SC, Hiragino Sans GB, Microsoft YaHei UI, Microsoft YaHei, Arial, sans-serif; letter-spacing: 0.544px; text-align: justify; white-space: normal; background-color: rgb(255, 255, 255); overflow-wrap: break-word !important;"><p style="margin-top: 0px; margin-bottom: 0px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; clear: both; min-height: 1em; overflow-wrap: break-word !important;"><br style="margin: 0px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; overflow-wrap: break-word !important;"/></p><p style="margin-top: 0px; margin-bottom: 0px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; clear: both; min-height: 1em; overflow-wrap: break-word !important;"><strong style="margin: 0px; padding: 0px; outline: 0px; max-width: 100%; color: rgb(141, 122, 186); box-sizing: border-box !important; overflow-wrap: break-word !important;">强化医保常态监管机制。</strong>枞阳县医保局对基金实行常态化监管，并在实践中不断发展完善。<strong style="margin: 0px; padding: 0px; outline: 0px; max-width: 100%; color: rgb(141, 122, 186); box-sizing: border-box !important; overflow-wrap: break-word !important;">一是</strong>建立和完善日常巡查、专项检查、飞行检查等多形式相结合的监督检查制度，对医疗机构进行全覆盖深查、细查。<strong style="margin: 0px; padding: 0px; outline: 0px; max-width: 100%; color: rgb(141, 122, 186); box-sizing: border-box !important; overflow-wrap: break-word !important;">二是</strong>建立县、乡、村三级医保基金监管体系，推进网格化管理。<strong style="margin: 0px; padding: 0px; outline: 0px; max-width: 100%; color: rgb(141, 122, 186); box-sizing: border-box !important; overflow-wrap: break-word !important;">三是</strong>加强医保稽核机构干部队伍建设，注重选配有医药、医保等专业背景的人员充实到医保稽核队伍。<strong style="margin: 0px; padding: 0px; outline: 0px; max-width: 100%; color: rgb(141, 122, 186); box-sizing: border-box !important; overflow-wrap: break-word !important;">四是</strong>完善协议管理制度，严格落实定点医疗机构动态管理和退出机制，凡是被查实欺诈骗保的定点医疗机构，符合暂停或者解除医保服务协议资格情形的，一律暂停或者解除；对财务制度、进销存记录等不健全，造成无账可查、无源可溯的，不予纳入定点，增强服务协议约束力。</p><p style="margin-top: 0px; margin-bottom: 0px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; clear: both; min-height: 1em; overflow-wrap: break-word !important;"><br style="margin: 0px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; overflow-wrap: break-word !important;"/></p><p style="margin-top: 0px; margin-bottom: 0px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; clear: both; min-height: 1em; overflow-wrap: break-word !important;">2021年以来，针对医保基金监管的新形势，在全县范围内开展以“回头看”为重点的4个专项行动，开展线上核查和现场稽核，依协议处理医疗机构19所、约谈3所、行政处罚2所，全县定点医疗机构稽核覆盖率100%，追回违规支付医保资金384.53万元，依协议核减扣款286.58万元，行政处罚80.08万元。</p><p style="margin-top: 0px; margin-bottom: 0px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; clear: both; min-height: 1em; overflow-wrap: break-word !important;"><br style="margin: 0px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; overflow-wrap: break-word !important;"/></p><p style="margin-top: 0px; margin-bottom: 0px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; clear: both; min-height: 1em; overflow-wrap: break-word !important;"><strong style="margin: 0px; padding: 0px; outline: 0px; max-width: 100%; color: rgb(141, 122, 186); box-sizing: border-box !important; overflow-wrap: break-word !important;">建立社会监督员制度。</strong>2021年5月，枞阳县医保局聘请“两代表一委员”、新闻工作者、财务工作者、参保群众代表共11人为医保社会监督员。负责义务宣传医疗保障相关法律法规和政策知识；对医保基金监管中存在的问题进行收集、提出意见和建议；对医保部门、医保经办机构、定点医疗机构及其工作人员进行社会监督。截至当年12月，收集到关于强化医院内控管理、加大基金监管力度、加强医保、卫健、市场监管、纪检监察联合处罚的建议3条。医保局及时核实调查、研究落实处理，并将结果及时反馈给社会监督员，产生了良好的社会效应。</p><p style="margin-top: 0px; margin-bottom: 0px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; clear: both; min-height: 1em; overflow-wrap: break-word !important;"><br style="margin: 0px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; overflow-wrap: break-word !important;"/></p><p style="margin-top: 0px; margin-bottom: 0px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; clear: both; min-height: 1em; overflow-wrap: break-word !important;"><strong style="margin: 0px; padding: 0px; outline: 0px; max-width: 100%; color: rgb(141, 122, 186); box-sizing: border-box !important; overflow-wrap: break-word !important;">建立部门联合惩戒机制。</strong>2021年，枞阳县先后建立医疗保障管理委员会、维护医保基金安全工作领导小组，形成政府牵头，医保、公安、卫健、市场监管、审计、财政、司法等多部门联动的基金监管协作机制，负责统筹协调基金监管重大行动、重大案件查处等工作。</p><p style="margin-top: 0px; margin-bottom: 0px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; clear: both; min-height: 1em; overflow-wrap: break-word !important;"><br style="margin: 0px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; overflow-wrap: break-word !important;"/></p><p style="margin-top: 0px; margin-bottom: 0px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; clear: both; min-height: 1em; overflow-wrap: break-word !important;">全年召开各部门联席会议4次，案件移送县纪委监委处理1起、移送县卫健委处理10起、移送公安机关查处6起；解除医保定点协议2家、暂停医保资金结算2家。</p><p style="margin-top: 0px; margin-bottom: 0px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; clear: both; min-height: 1em; overflow-wrap: break-word !important;"><br style="margin: 0px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; overflow-wrap: break-word !important;"/></p><p style="margin-top: 0px; margin-bottom: 0px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; clear: both; min-height: 1em; overflow-wrap: break-word !important;"><strong style="margin: 0px; padding: 0px; outline: 0px; max-width: 100%; color: rgb(141, 122, 186); box-sizing: border-box !important; overflow-wrap: break-word !important;">建立违规问题整改清单制度。</strong>枞阳县医保局逐步建立医疗保障违规问题整改清单制度，明确整改流程。<strong style="margin: 0px; padding: 0px; outline: 0px; max-width: 100%; color: rgb(141, 122, 186); box-sizing: border-box !important; overflow-wrap: break-word !important;">一是</strong>每次稽核发现的违规问题，结合医疗机构申诉意见，经局长办公会议集中研究处理，再对医疗机构发出违规问题处理通知书或行政处罚立案通知书；<strong style="margin: 0px; padding: 0px; outline: 0px; max-width: 100%; color: rgb(141, 122, 186); box-sizing: border-box !important; overflow-wrap: break-word !important;">二是</strong>建立整改清单制度，要求定点医疗机构对医保违规的问题限期整改，并建立违规问题、整改措施、责任人、整改时限四项“整改清单”制度，整改结果书面报送县医保局备案，对医保违规问题整改不到位或拒不整改的，根据《医疗保障基金使用监督管理条例》或定点医疗机构服务协议加倍进行处罚；<strong style="margin: 0px; padding: 0px; outline: 0px; max-width: 100%; color: rgb(141, 122, 186); box-sizing: border-box !important; overflow-wrap: break-word !important;">三是</strong>定期对违规医保支付10万元以上案例进行曝光，公开曝光4起违规案件。</p><p style="margin-top: 0px; margin-bottom: 0px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; clear: both; min-height: 1em; overflow-wrap: break-word !important;"><br style="margin: 0px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; overflow-wrap: break-word !important;"/></p><p style="margin-top: 0px; margin-bottom: 0px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; clear: both; min-height: 1em; overflow-wrap: break-word !important;"><strong style="margin: 0px; padding: 0px; outline: 0px; max-width: 100%; color: rgb(141, 122, 186); box-sizing: border-box !important; overflow-wrap: break-word !important;">畅通欺诈骗保举报途径。</strong>会同县财政部门对举报欺诈骗取医保基金行为实施奖励，对举报案件即办、即查、即处理。截至2021年底，及时受理、查处举报案件3起，追回医保基金115.27万元，其中移送公安部门查处1起。</p><p style="margin-top: 0px; margin-bottom: 0px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; clear: both; min-height: 1em; overflow-wrap: break-word !important;"><br style="margin: 0px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; overflow-wrap: break-word !important;"/></p></section><section powered-by="xiumi.us" style="margin: 10px 0px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; color: rgb(34, 34, 34); font-family: -apple-system, BlinkMacSystemFont, Helvetica Neue, PingFang SC, Hiragino Sans GB, Microsoft YaHei UI, Microsoft YaHei, Arial, sans-serif; letter-spacing: 0.544px; white-space: normal; background-color: rgb(255, 255, 255); overflow-wrap: break-word !important;"><section style="margin: 0px; padding: 0px 0px 0px 30px; outline: 0px; max-width: 100%; box-sizing: border-box; overflow-wrap: break-word !important; display: inline-block; min-width: 10%; vertical-align: top;"><section powered-by="xiumi.us" style="margin: 0px 0px -30px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; overflow-wrap: break-word !important; transform: translate3d(-30px, 0px, 0px);"><section style="margin: 0px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; overflow-wrap: break-word !important; display: inline-block; width: 30px; height: 30px; vertical-align: top; overflow: hidden; border-width: 0px; border-radius: 100%; border-style: none; border-color: rgba(118, 178, 124, 0); background-color: rgba(141, 122, 186, 0.3);"><section powered-by="xiumi.us" style="margin: 0px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; overflow-wrap: break-word !important; text-align: justify;"><p style="margin-top: 0px; margin-bottom: 0px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; clear: both; min-height: 1em; overflow-wrap: break-word !important;"><br style="margin: 0px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; overflow-wrap: break-word !important;"/></p></section></section></section><section powered-by="xiumi.us" style="margin: 0px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; overflow-wrap: break-word !important; transform: translate3d(-15px, 0px, 0px);"><section style="margin: 0px; padding: 3px 0px; outline: 0px; max-width: 100%; box-sizing: border-box; overflow-wrap: break-word !important; display: inline-block; min-width: 10%; vertical-align: top;"><section powered-by="xiumi.us" style="margin: 0px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; overflow-wrap: break-word !important; color: rgb(141, 122, 186); text-align: justify;"><p style="margin-top: 0px; margin-bottom: 0px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; clear: both; min-height: 1em; overflow-wrap: break-word !important;"><strong style="margin: 0px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; overflow-wrap: break-word !important;">3 .完善基金监管机制</strong></p></section></section></section></section></section><section powered-by="xiumi.us" style="margin: 0px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; color: rgb(34, 34, 34); font-family: -apple-system, BlinkMacSystemFont, Helvetica Neue, PingFang SC, Hiragino Sans GB, Microsoft YaHei UI, Microsoft YaHei, Arial, sans-serif; letter-spacing: 0.544px; text-align: justify; white-space: normal; background-color: rgb(255, 255, 255); overflow-wrap: break-word !important;"><p style="margin-top: 0px; margin-bottom: 0px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; clear: both; min-height: 1em; overflow-wrap: break-word !important;"><br style="margin: 0px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; overflow-wrap: break-word !important;"/></p><p style="margin-top: 0px; margin-bottom: 0px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; clear: both; min-height: 1em; overflow-wrap: break-word !important;"><strong style="margin: 0px; padding: 0px; outline: 0px; max-width: 100%; color: rgb(141, 122, 186); box-sizing: border-box !important; overflow-wrap: break-word !important;">建立基金运行分析约谈制度。</strong>利用医保联网结算数据，分月、分季度、分年度对定点医疗机构医保基金使用情况、稽核发现的违规问题进行统计分析、通报。每季度约谈数据异常的医疗机构，针对问题面对面地与医疗机构进行分析、查摆，共同研判、落实整改、促进规范。</p><p style="margin-top: 0px; margin-bottom: 0px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; clear: both; min-height: 1em; overflow-wrap: break-word !important;"><br style="margin: 0px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; overflow-wrap: break-word !important;"/></p><p style="margin-top: 0px; margin-bottom: 0px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; clear: both; min-height: 1em; overflow-wrap: break-word !important;">2021年运行分析约谈制度建立以来，共发现次均费增长过快、分解住院等问题线索48个，处理医疗机构19所，有效遏制了各种违规行为，药品费、耗材费、检查费“三费”增长幅度明显下降。</p><p style="margin-top: 0px; margin-bottom: 0px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; clear: both; min-height: 1em; overflow-wrap: break-word !important;"><br style="margin: 0px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; overflow-wrap: break-word !important;"/></p><p style="margin-top: 0px; margin-bottom: 0px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; clear: both; min-height: 1em; overflow-wrap: break-word !important;"><strong style="margin: 0px; padding: 0px; outline: 0px; max-width: 100%; color: rgb(141, 122, 186); box-sizing: border-box !important; overflow-wrap: break-word !important;">建立医保工作质效考核制度。</strong>强化定点医疗机构履约责任，制定了《枞阳县定点医疗机构（住院）医保工作质效考核评价暂行办法》，从基础管理、诊疗服务、费用管理、改革协同、基金监管5个方面设立考核评价指标。将对医疗机构的日常检查、投诉举报处理、飞行检查、智能审核、大数据筛查等纳入考核内容。同时，建立定点医疗机构医保工作质量保证金制度，将医疗机构每月应付基金总额的5%作为质量保证金，与考核结果挂钩。年终清算时对考评为合格等次的全额返还保证金；考评为基本合格等次的，扣减保证金的30%；不合格等次的扣减全部保证金。</p><p style="margin-top: 0px; margin-bottom: 0px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; clear: both; min-height: 1em; overflow-wrap: break-word !important;"><br style="margin: 0px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; overflow-wrap: break-word !important;"/></p><p style="margin-top: 0px; margin-bottom: 0px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; clear: both; min-height: 1em; overflow-wrap: break-word !important;"><strong style="margin: 0px; padding: 0px; outline: 0px; max-width: 100%; color: rgb(141, 122, 186); box-sizing: border-box !important; overflow-wrap: break-word !important;">强化医保医师监督管理。</strong>按照国家统一标准，在“国家医保信息业务编码标准数据库动态维护”平台上将全县定点医疗机构共2165名医保医师、医保护士信息录入了管理系统，并签订《维护医保基金安全承诺书》。对医保医师、医保护士进行实时动态监控、记分管理，防止医保基金“跑冒滴漏”现象发生，有效遏制大处方、重复检查、乱收费、套取医保基金等违法违规行为。</p><p style="margin-top: 0px; margin-bottom: 0px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; clear: both; min-height: 1em; overflow-wrap: break-word !important;"><br style="margin: 0px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; overflow-wrap: break-word !important;"/></p><p style="margin-top: 0px; margin-bottom: 0px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; clear: both; min-height: 1em; overflow-wrap: break-word !important;">截至2021年年底，已对5名医保医师进行了扣分处理，暂停医保医师资格1人，起到了警示和震慑作用。</p><p style="margin-top: 0px; margin-bottom: 0px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; clear: both; min-height: 1em; overflow-wrap: break-word !important;"><br style="margin: 0px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box !important; overflow-wrap: break-word !important;"/></p><p style="margin-top: 0px; margin-bottom: 0px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; clear: both; min-height: 1em; text-align: center; overflow-wrap: break-word !important;"></p><p style="margin-top: 0px; margin-bottom: 0px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; clear: both; min-height: 1em; overflow-wrap: break-word !important;"><br style="margin: 0px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box !important; overflow-wrap: break-word !important;"/></p></section><section powered-by="xiumi.us" style="margin: 0px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; color: rgb(34, 34, 34); font-family: -apple-system, BlinkMacSystemFont, Helvetica Neue, PingFang SC, Hiragino Sans GB, Microsoft YaHei UI, Microsoft YaHei, Arial, sans-serif; letter-spacing: 0.544px; text-align: justify; white-space: normal; background-color: rgb(255, 255, 255); overflow-wrap: break-word !important;"><section style="margin: 0px 0px 10px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; overflow-wrap: break-word !important; text-align: center; justify-content: center; display: flex; flex-flow: row nowrap;"><section style="margin: 0px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; overflow-wrap: break-word !important; display: inline-block; width: auto; vertical-align: top; line-height: 0; background-image: linear-gradient(rgb(165, 145, 186) 0%, rgb(141, 122, 186) 100%); min-width: 10%; flex: 0 0 auto; height: auto; align-self: flex-start;"><section powered-by="xiumi.us" style="margin: 0px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; overflow-wrap: break-word !important;"><section style="margin: 0px 0px 3px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; overflow-wrap: break-word !important; transform: translate3d(-3px, 0px, 0px); justify-content: center; display: flex; flex-flow: row nowrap;"><section style="margin: 0px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; overflow-wrap: break-word !important; display: inline-block; width: 128px; vertical-align: top; background-color: rgba(255, 255, 255, 0.76); line-height: 2; border-bottom: 0px none rgb(62, 62, 62); border-bottom-right-radius: 15px; overflow: hidden; align-self: flex-start; flex: 0 0 auto;"><section powered-by="xiumi.us" style="margin: 4px 0px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; overflow-wrap: break-word !important; transform: translate3d(4px, 0px, 0px);"><section style="margin: 0px; padding: 0px 13px; outline: 0px; max-width: 100%; box-sizing: border-box; overflow-wrap: break-word !important; color: rgb(36, 30, 52); line-height: 1.8; letter-spacing: 1px; text-align: justify;"><p style="margin-top: 0px; margin-bottom: 0px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; clear: both; min-height: 1em; overflow-wrap: break-word !important;"><strong style="margin: 0px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; overflow-wrap: break-word !important;">二、存在问题</strong></p></section></section></section></section></section></section></section></section><section powered-by="xiumi.us" style="margin: 0px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; color: rgb(34, 34, 34); font-family: -apple-system, BlinkMacSystemFont, Helvetica Neue, PingFang SC, Hiragino Sans GB, Microsoft YaHei UI, Microsoft YaHei, Arial, sans-serif; letter-spacing: 0.544px; text-align: justify; white-space: normal; background-color: rgb(255, 255, 255); overflow-wrap: break-word !important;"><p style="margin-top: 0px; margin-bottom: 0px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; clear: both; min-height: 1em; overflow-wrap: break-word !important;"><br style="margin: 0px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; overflow-wrap: break-word !important;"/></p></section><section powered-by="xiumi.us" style="margin: 10px 0px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; color: rgb(34, 34, 34); font-family: -apple-system, BlinkMacSystemFont, Helvetica Neue, PingFang SC, Hiragino Sans GB, Microsoft YaHei UI, Microsoft YaHei, Arial, sans-serif; letter-spacing: 0.544px; white-space: normal; background-color: rgb(255, 255, 255); overflow-wrap: break-word !important;"><section style="margin: 0px; padding: 0px 0px 0px 30px; outline: 0px; max-width: 100%; box-sizing: border-box; overflow-wrap: break-word !important; display: inline-block; min-width: 10%; vertical-align: top;"><section powered-by="xiumi.us" style="margin: 0px 0px -30px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; overflow-wrap: break-word !important; transform: translate3d(-30px, 0px, 0px);"><section style="margin: 0px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; overflow-wrap: break-word !important; display: inline-block; width: 30px; height: 30px; vertical-align: top; overflow: hidden; border-width: 0px; border-radius: 100%; border-style: none; border-color: rgba(118, 178, 124, 0); background-color: rgba(141, 122, 186, 0.3);"><section powered-by="xiumi.us" style="margin: 0px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; overflow-wrap: break-word !important; text-align: justify;"><p style="margin-top: 0px; margin-bottom: 0px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; clear: both; min-height: 1em; overflow-wrap: break-word !important;"><br style="margin: 0px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; overflow-wrap: break-word !important;"/></p></section></section></section><section powered-by="xiumi.us" style="margin: 0px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; overflow-wrap: break-word !important; transform: translate3d(-15px, 0px, 0px);"><section style="margin: 0px; padding: 3px 0px; outline: 0px; max-width: 100%; box-sizing: border-box; overflow-wrap: break-word !important; display: inline-block; min-width: 10%; vertical-align: top;"><section powered-by="xiumi.us" style="margin: 0px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; overflow-wrap: break-word !important; color: rgb(141, 122, 186); text-align: justify;"><p style="margin-top: 0px; margin-bottom: 0px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; clear: both; min-height: 1em; overflow-wrap: break-word !important;"><strong style="margin: 0px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; overflow-wrap: break-word !important;">1.医保行政执法力量有待进一步加强</strong></p></section></section></section></section></section><section powered-by="xiumi.us" style="margin: 0px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; color: rgb(34, 34, 34); font-family: -apple-system, BlinkMacSystemFont, Helvetica Neue, PingFang SC, Hiragino Sans GB, Microsoft YaHei UI, Microsoft YaHei, Arial, sans-serif; letter-spacing: 0.544px; text-align: justify; white-space: normal; background-color: rgb(255, 255, 255); overflow-wrap: break-word !important;"><p style="margin-top: 0px; margin-bottom: 0px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; clear: both; min-height: 1em; overflow-wrap: break-word !important;"><br style="margin: 0px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; overflow-wrap: break-word !important;"/></p><p style="margin-top: 0px; margin-bottom: 0px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; clear: both; min-height: 1em; overflow-wrap: break-word !important;">医疗保障行政部门成立后，医保基金监管由专职部门开展，对各种欺诈骗保行为的打击形成了高压态势，但在基层由于医保行政部门编制少，缺乏专职医保行政执行队伍和专业的稽核人员，所以医保监管主要靠业务经办人员兼职参与。枞阳县医保局成立后，只有6个行政编制，下设了一个医疗保障管理服务中心，基金监督主要是业务经办人员兼职，既负责经办又承担行政执法、稽核监管，职能不清，责任难以落实到人。</p><p style="margin-top: 0px; margin-bottom: 0px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; clear: both; min-height: 1em; overflow-wrap: break-word !important;"><br style="margin: 0px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; overflow-wrap: break-word !important;"/></p></section><section powered-by="xiumi.us" style="margin: 10px 0px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; color: rgb(34, 34, 34); font-family: -apple-system, BlinkMacSystemFont, Helvetica Neue, PingFang SC, Hiragino Sans GB, Microsoft YaHei UI, Microsoft YaHei, Arial, sans-serif; letter-spacing: 0.544px; white-space: normal; background-color: rgb(255, 255, 255); overflow-wrap: break-word !important;"><section style="margin: 0px; padding: 0px 0px 0px 30px; outline: 0px; max-width: 100%; box-sizing: border-box; overflow-wrap: break-word !important; display: inline-block; min-width: 10%; vertical-align: top;"><section powered-by="xiumi.us" style="margin: 0px 0px -30px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; overflow-wrap: break-word !important; transform: translate3d(-30px, 0px, 0px);"><section style="margin: 0px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; overflow-wrap: break-word !important; display: inline-block; width: 30px; height: 30px; vertical-align: top; overflow: hidden; border-width: 0px; border-radius: 100%; border-style: none; border-color: rgba(118, 178, 124, 0); background-color: rgba(141, 122, 186, 0.3);"><section powered-by="xiumi.us" style="margin: 0px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; overflow-wrap: break-word !important; text-align: justify;"><p style="margin-top: 0px; margin-bottom: 0px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; clear: both; min-height: 1em; overflow-wrap: break-word !important;"><br style="margin: 0px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; overflow-wrap: break-word !important;"/></p></section></section></section><section powered-by="xiumi.us" style="margin: 0px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; overflow-wrap: break-word !important; transform: translate3d(-15px, 0px, 0px);"><section style="margin: 0px; padding: 3px 0px; outline: 0px; max-width: 100%; box-sizing: border-box; overflow-wrap: break-word !important; display: inline-block; min-width: 10%; vertical-align: top;"><section powered-by="xiumi.us" style="margin: 0px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; overflow-wrap: break-word !important; color: rgb(141, 122, 186); text-align: justify;"><p style="margin-top: 0px; margin-bottom: 0px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; clear: both; min-height: 1em; overflow-wrap: break-word !important;"><strong style="margin: 0px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; overflow-wrap: break-word !important;">2.协同监管机制尚未形成联合惩戒合力</strong></p></section></section></section></section></section><section powered-by="xiumi.us" style="margin: 0px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; color: rgb(34, 34, 34); font-family: -apple-system, BlinkMacSystemFont, Helvetica Neue, PingFang SC, Hiragino Sans GB, Microsoft YaHei UI, Microsoft YaHei, Arial, sans-serif; letter-spacing: 0.544px; text-align: justify; white-space: normal; background-color: rgb(255, 255, 255); overflow-wrap: break-word !important;"><p style="margin-top: 0px; margin-bottom: 0px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; clear: both; min-height: 1em; overflow-wrap: break-word !important;"><br style="margin: 0px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; overflow-wrap: break-word !important;"/></p><p style="margin-top: 0px; margin-bottom: 0px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; clear: both; min-height: 1em; overflow-wrap: break-word !important;">枞阳县医保局引入第三方参与监管，一定程度上解决了人员不足的问题，但其运行机制尚未实现常态化；医保、卫健部门均对医疗机构的监督管理存在行业壁垒，难以做到信息共享、畅通；另外，医保基金监管联席会议制度建立后，畅通了欺诈骗保案件部门协作配合、信息共享机制，但对医保违法违规行为联合惩戒还未达到预期效果。</p><p style="margin-top: 0px; margin-bottom: 0px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; clear: both; min-height: 1em; overflow-wrap: break-word !important;"><br style="margin: 0px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; overflow-wrap: break-word !important;"/></p></section><section powered-by="xiumi.us" style="margin: 10px 0px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; color: rgb(34, 34, 34); font-family: -apple-system, BlinkMacSystemFont, Helvetica Neue, PingFang SC, Hiragino Sans GB, Microsoft YaHei UI, Microsoft YaHei, Arial, sans-serif; letter-spacing: 0.544px; white-space: normal; background-color: rgb(255, 255, 255); overflow-wrap: break-word !important;"><section style="margin: 0px; padding: 0px 0px 0px 30px; outline: 0px; max-width: 100%; box-sizing: border-box; overflow-wrap: break-word !important; display: inline-block; min-width: 10%; vertical-align: top;"><section powered-by="xiumi.us" style="margin: 0px 0px -30px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; overflow-wrap: break-word !important; transform: translate3d(-30px, 0px, 0px);"><section style="margin: 0px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; overflow-wrap: break-word !important; display: inline-block; width: 30px; height: 30px; vertical-align: top; overflow: hidden; border-width: 0px; border-radius: 100%; border-style: none; border-color: rgba(118, 178, 124, 0); background-color: rgba(141, 122, 186, 0.3);"><section powered-by="xiumi.us" style="margin: 0px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; overflow-wrap: break-word !important; text-align: justify;"><p style="margin-top: 0px; margin-bottom: 0px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; clear: both; min-height: 1em; overflow-wrap: break-word !important;"><br style="margin: 0px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; overflow-wrap: break-word !important;"/></p></section></section></section><section powered-by="xiumi.us" style="margin: 0px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; overflow-wrap: break-word !important; transform: translate3d(-15px, 0px, 0px);"><section style="margin: 0px; padding: 3px 0px; outline: 0px; max-width: 100%; box-sizing: border-box; overflow-wrap: break-word !important; display: inline-block; min-width: 10%; vertical-align: top;"><section powered-by="xiumi.us" style="margin: 0px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; overflow-wrap: break-word !important; color: rgb(141, 122, 186); text-align: justify;"><p style="margin-top: 0px; margin-bottom: 0px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; clear: both; min-height: 1em; overflow-wrap: break-word !important;"><strong style="margin: 0px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; overflow-wrap: break-word !important;">3.对医疗机构违规行为的稽核认定难度大</strong></p></section></section></section></section></section><section powered-by="xiumi.us" style="margin: 0px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; color: rgb(34, 34, 34); font-family: -apple-system, BlinkMacSystemFont, Helvetica Neue, PingFang SC, Hiragino Sans GB, Microsoft YaHei UI, Microsoft YaHei, Arial, sans-serif; letter-spacing: 0.544px; text-align: justify; white-space: normal; background-color: rgb(255, 255, 255); overflow-wrap: break-word !important;"><p style="margin-top: 0px; margin-bottom: 0px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; clear: both; min-height: 1em; overflow-wrap: break-word !important;"><br style="margin: 0px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; overflow-wrap: break-word !important;"/></p><p style="margin-top: 0px; margin-bottom: 0px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; clear: both; min-height: 1em; overflow-wrap: break-word !important;">随着监管力度不断加大，有效遏制了医疗机构医保违规行为，但医保违规行为日益呈现隐蔽性、多样化趋势，给稽核认定带来了诸多困难。主要表现为：一是医疗机构为增加收入，低标准收治住院病人，稽核时需要通过调阅病历记录、入户调查等方式认定，工作量多、耗时长、难度大。二是协议医疗机构伪造处方、病历、发票、检验报告等信息，单靠病历判断真伪的难度大。三是医学检查结果互认执行率不高，病人在医疗机构之间存在过度检查、重复检查，基金监管缺乏政策依据。四是医保限定条件支付的药品如何认定、是否规范使用存在争议，临床医生认为根据病情应该使用，医保限定条件不予支付的情况时有发生。五是参保人员结构复杂，入户调查取证难度大。</p><p style="margin-top: 0px; margin-bottom: 0px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; clear: both; min-height: 1em; overflow-wrap: break-word !important;"><br style="margin: 0px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; overflow-wrap: break-word !important;"/></p></section><section powered-by="xiumi.us" style="margin: 10px 0px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; color: rgb(34, 34, 34); font-family: -apple-system, BlinkMacSystemFont, Helvetica Neue, PingFang SC, Hiragino Sans GB, Microsoft YaHei UI, Microsoft YaHei, Arial, sans-serif; letter-spacing: 0.544px; white-space: normal; background-color: rgb(255, 255, 255); overflow-wrap: break-word !important;"><section style="margin: 0px; padding: 0px 0px 0px 30px; outline: 0px; max-width: 100%; box-sizing: border-box; overflow-wrap: break-word !important; display: inline-block; min-width: 10%; vertical-align: top;"><section powered-by="xiumi.us" style="margin: 0px 0px -30px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; overflow-wrap: break-word !important; transform: translate3d(-30px, 0px, 0px);"><section style="margin: 0px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; overflow-wrap: break-word !important; display: inline-block; width: 30px; height: 30px; vertical-align: top; overflow: hidden; border-width: 0px; border-radius: 100%; border-style: none; border-color: rgba(118, 178, 124, 0); background-color: rgba(141, 122, 186, 0.3);"><section powered-by="xiumi.us" style="margin: 0px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; overflow-wrap: break-word !important; text-align: justify;"><p style="margin-top: 0px; margin-bottom: 0px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; clear: both; min-height: 1em; overflow-wrap: break-word !important;"><br style="margin: 0px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; overflow-wrap: break-word !important;"/></p></section></section></section><section powered-by="xiumi.us" style="margin: 0px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; overflow-wrap: break-word !important; transform: translate3d(-15px, 0px, 0px);"><section style="margin: 0px; padding: 3px 0px; outline: 0px; max-width: 100%; box-sizing: border-box; overflow-wrap: break-word !important; display: inline-block; min-width: 10%; vertical-align: top;"><section powered-by="xiumi.us" style="margin: 0px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; overflow-wrap: break-word !important; color: rgb(141, 122, 186); text-align: justify;"><p style="margin-top: 0px; margin-bottom: 0px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; clear: both; min-height: 1em; overflow-wrap: break-word !important;"><strong style="margin: 0px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; overflow-wrap: break-word !important;">4.医保信用评价机制有待规范和完善</strong></p></section></section></section></section></section><section powered-by="xiumi.us" style="margin: 0px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; color: rgb(34, 34, 34); font-family: -apple-system, BlinkMacSystemFont, Helvetica Neue, PingFang SC, Hiragino Sans GB, Microsoft YaHei UI, Microsoft YaHei, Arial, sans-serif; letter-spacing: 0.544px; text-align: justify; white-space: normal; background-color: rgb(255, 255, 255); overflow-wrap: break-word !important;"><p style="margin-top: 0px; margin-bottom: 0px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; clear: both; min-height: 1em; overflow-wrap: break-word !important;"><br style="margin: 0px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; overflow-wrap: break-word !important;"/></p><p style="margin-top: 0px; margin-bottom: 0px; padding: 0px; outline: 0px; max-width: 100%; clear: both; min-height: 1em; box-sizing: border-box !important; overflow-wrap: break-word !important;">目前，各地医保信用评价推行进展不一、评价标准不同，影响了定点医疗机构信用评价机制在医保等领域的应用。<strong style="margin: 0px; padding: 0px; outline: 0px; max-width: 100%; color: rgb(141, 122, 186); box-sizing: border-box !important; overflow-wrap: break-word !important;">一是</strong>评价标准需要具体细化，依据服务协议和信用评价办法来确定评价范围。随着药品集采不断扩大、第三方机构参与基金监管、经办机构内控风险防范等新形势、新任务，需要医保行政部门进一步具体细化充实考核内容、扩大考核范围。<strong style="margin: 0px; padding: 0px; outline: 0px; max-width: 100%; color: rgb(141, 122, 186); box-sizing: border-box !important; overflow-wrap: break-word !important;">二是</strong>医保信息规范性和监管系统需要提升，目前信用信息共享平台、医疗机构采购平台和医保相关数据业务系统、监管系统还未互联互通，信息无法共享。<strong style="margin: 0px; padding: 0px; outline: 0px; max-width: 100%; color: rgb(141, 122, 186); box-sizing: border-box !important; overflow-wrap: break-word !important;">三是</strong>对失信单位和个人在考核结果运用时由于涉及多部门，适用的行业法律、法规也较多，尚缺乏有效的联合惩戒措施和手段。</p><p style="margin-top: 0px; margin-bottom: 0px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; clear: both; min-height: 1em; overflow-wrap: break-word !important;"><br style="margin: 0px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; overflow-wrap: break-word !important;"/></p></section><section powered-by="xiumi.us" style="margin: 0px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; color: rgb(34, 34, 34); font-family: -apple-system, BlinkMacSystemFont, Helvetica Neue, PingFang SC, Hiragino Sans GB, Microsoft YaHei UI, Microsoft YaHei, Arial, sans-serif; letter-spacing: 0.544px; text-align: justify; white-space: normal; background-color: rgb(255, 255, 255); overflow-wrap: break-word !important;"><section style="margin: 0px 0px 10px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; overflow-wrap: break-word !important; text-align: center; justify-content: center; display: flex; flex-flow: row nowrap;"><section style="margin: 0px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; overflow-wrap: break-word !important; display: inline-block; width: auto; vertical-align: top; line-height: 0; background-image: linear-gradient(rgb(165, 145, 186) 0%, rgb(141, 122, 186) 100%); min-width: 10%; flex: 0 0 auto; height: auto; align-self: flex-start;"><section powered-by="xiumi.us" style="margin: 0px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; overflow-wrap: break-word !important;"><section style="margin: 0px 0px 3px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; overflow-wrap: break-word !important; transform: translate3d(-3px, 0px, 0px); justify-content: center; display: flex; flex-flow: row nowrap;"><section style="margin: 0px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; overflow-wrap: break-word !important; display: inline-block; width: 145px; vertical-align: top; background-color: rgba(255, 255, 255, 0.76); line-height: 2; border-bottom: 0px none rgb(62, 62, 62); border-bottom-right-radius: 15px; overflow: hidden; align-self: flex-start; flex: 0 0 auto;"><section powered-by="xiumi.us" style="margin: 4px 0px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; overflow-wrap: break-word !important; transform: translate3d(4px, 0px, 0px);"><section style="margin: 0px; padding: 0px 13px; outline: 0px; max-width: 100%; box-sizing: border-box; overflow-wrap: break-word !important; color: rgb(36, 30, 52); line-height: 1.8; letter-spacing: 1px; text-align: justify;"><p style="margin-top: 0px; margin-bottom: 0px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; clear: both; min-height: 1em; overflow-wrap: break-word !important;"><strong style="margin: 0px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; overflow-wrap: break-word !important;">三、对策与建议</strong></p></section></section></section></section></section></section></section></section><section powered-by="xiumi.us" style="margin: 0px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; color: rgb(34, 34, 34); font-family: -apple-system, BlinkMacSystemFont, Helvetica Neue, PingFang SC, Hiragino Sans GB, Microsoft YaHei UI, Microsoft YaHei, Arial, sans-serif; letter-spacing: 0.544px; text-align: justify; white-space: normal; background-color: rgb(255, 255, 255); overflow-wrap: break-word !important;"><p style="margin-top: 0px; margin-bottom: 0px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; clear: both; min-height: 1em; overflow-wrap: break-word !important;"><br style="margin: 0px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; overflow-wrap: break-word !important;"/></p></section><section powered-by="xiumi.us" style="margin: 10px 0px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; color: rgb(34, 34, 34); font-family: -apple-system, BlinkMacSystemFont, Helvetica Neue, PingFang SC, Hiragino Sans GB, Microsoft YaHei UI, Microsoft YaHei, Arial, sans-serif; letter-spacing: 0.544px; white-space: normal; background-color: rgb(255, 255, 255); overflow-wrap: break-word !important;"><section style="margin: 0px; padding: 0px 0px 0px 30px; outline: 0px; max-width: 100%; box-sizing: border-box; overflow-wrap: break-word !important; display: inline-block; min-width: 10%; vertical-align: top;"><section powered-by="xiumi.us" style="margin: 0px 0px -30px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; overflow-wrap: break-word !important; transform: translate3d(-30px, 0px, 0px);"><section style="margin: 0px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; overflow-wrap: break-word !important; display: inline-block; width: 30px; height: 30px; vertical-align: top; overflow: hidden; border-width: 0px; border-radius: 100%; border-style: none; border-color: rgba(118, 178, 124, 0); background-color: rgba(141, 122, 186, 0.3);"><section powered-by="xiumi.us" style="margin: 0px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; overflow-wrap: break-word !important; text-align: justify;"><p style="margin-top: 0px; margin-bottom: 0px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; clear: both; min-height: 1em; overflow-wrap: break-word !important;"><br style="margin: 0px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; overflow-wrap: break-word !important;"/></p></section></section></section><section powered-by="xiumi.us" style="margin: 0px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; overflow-wrap: break-word !important; transform: translate3d(-15px, 0px, 0px);"><section style="margin: 0px; padding: 3px 0px; outline: 0px; max-width: 100%; box-sizing: border-box; overflow-wrap: break-word !important; display: inline-block; min-width: 10%; vertical-align: top;"><section powered-by="xiumi.us" style="margin: 0px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; overflow-wrap: break-word !important; color: rgb(141, 122, 186); text-align: justify;"><p style="margin-top: 0px; margin-bottom: 0px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; clear: both; min-height: 1em; overflow-wrap: break-word !important;"><strong style="margin: 0px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; overflow-wrap: break-word !important;">1.强化基金监管队伍建设</strong></p></section></section></section></section></section><section powered-by="xiumi.us" style="margin: 0px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; color: rgb(34, 34, 34); font-family: -apple-system, BlinkMacSystemFont, Helvetica Neue, PingFang SC, Hiragino Sans GB, Microsoft YaHei UI, Microsoft YaHei, Arial, sans-serif; letter-spacing: 0.544px; text-align: justify; white-space: normal; background-color: rgb(255, 255, 255); overflow-wrap: break-word !important;"><p style="margin-top: 0px; margin-bottom: 0px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; clear: both; min-height: 1em; overflow-wrap: break-word !important;"><br style="margin: 0px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; overflow-wrap: break-word !important;"/></p><p style="margin-top: 0px; margin-bottom: 0px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; clear: both; min-height: 1em; overflow-wrap: break-word !important;">建议强化医保执法队伍建设，成立基层医保基金监管专职机构，配齐配强行政执法人员。组建以医保基金稽核业务骨干为核心，以医药、财务、计算机技术、科研、审计等五方面人员为支撑的“1+5”专职队伍，理顺医疗保障行政监管、稽核检查与经办协议管理关系，明确行政监管与经办稽核的职责边界，规范医保监管行为。</p><p style="margin-top: 0px; margin-bottom: 0px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; clear: both; min-height: 1em; overflow-wrap: break-word !important;"><br style="margin: 0px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box !important; overflow-wrap: break-word !important;"/></p><p style="margin-top: 0px; margin-bottom: 0px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; clear: both; min-height: 1em; text-align: center; overflow-wrap: break-word !important;"></p><p style="margin-top: 0px; margin-bottom: 0px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; clear: both; min-height: 1em; overflow-wrap: break-word !important;"><br style="margin: 0px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box !important; overflow-wrap: break-word !important;"/></p></section><section powered-by="xiumi.us" style="margin: 10px 0px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; color: rgb(34, 34, 34); font-family: -apple-system, BlinkMacSystemFont, Helvetica Neue, PingFang SC, Hiragino Sans GB, Microsoft YaHei UI, Microsoft YaHei, Arial, sans-serif; letter-spacing: 0.544px; white-space: normal; background-color: rgb(255, 255, 255); overflow-wrap: break-word !important;"><section style="margin: 0px; padding: 0px 0px 0px 30px; outline: 0px; max-width: 100%; box-sizing: border-box; overflow-wrap: break-word !important; display: inline-block; min-width: 10%; vertical-align: top;"><section powered-by="xiumi.us" style="margin: 0px 0px -30px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; overflow-wrap: break-word !important; transform: translate3d(-30px, 0px, 0px);"><section style="margin: 0px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; overflow-wrap: break-word !important; display: inline-block; width: 30px; height: 30px; vertical-align: top; overflow: hidden; border-width: 0px; border-radius: 100%; border-style: none; border-color: rgba(118, 178, 124, 0); background-color: rgba(141, 122, 186, 0.3);"><section powered-by="xiumi.us" style="margin: 0px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; overflow-wrap: break-word !important; text-align: justify;"><p style="margin-top: 0px; margin-bottom: 0px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; clear: both; min-height: 1em; overflow-wrap: break-word !important;"><br style="margin: 0px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; overflow-wrap: break-word !important;"/></p></section></section></section><section powered-by="xiumi.us" style="margin: 0px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; overflow-wrap: break-word !important; transform: translate3d(-15px, 0px, 0px);"><section style="margin: 0px; padding: 3px 0px; outline: 0px; max-width: 100%; box-sizing: border-box; overflow-wrap: break-word !important; display: inline-block; min-width: 10%; vertical-align: top;"><section powered-by="xiumi.us" style="margin: 0px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; overflow-wrap: break-word !important; color: rgb(141, 122, 186); text-align: justify;"><p style="margin-top: 0px; margin-bottom: 0px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; clear: both; min-height: 1em; overflow-wrap: break-word !important;"><strong style="margin: 0px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; overflow-wrap: break-word !important;">2.强化多部门联合惩戒机制</strong></p></section></section></section></section></section><section powered-by="xiumi.us" style="margin: 0px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; color: rgb(34, 34, 34); font-family: -apple-system, BlinkMacSystemFont, Helvetica Neue, PingFang SC, Hiragino Sans GB, Microsoft YaHei UI, Microsoft YaHei, Arial, sans-serif; letter-spacing: 0.544px; text-align: justify; white-space: normal; background-color: rgb(255, 255, 255); overflow-wrap: break-word !important;"><p style="margin-top: 0px; margin-bottom: 0px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; clear: both; min-height: 1em; overflow-wrap: break-word !important;"><br style="margin: 0px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; overflow-wrap: break-word !important;"/></p><p style="margin-top: 0px; margin-bottom: 0px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; clear: both; min-height: 1em; overflow-wrap: break-word !important;">医保部门要进一步强化定点医疗机构的协议管理，加强行政执法。同时要探索建立医保违法违规行为常态化线索相互移送机制，对欺诈骗保涉嫌违纪、违法的相关责任人、单位按规定移送纪委监委、公安部门查处，对涉及行业主管部门的违规行为，按规定移送卫生健康、市场监管、医保部门查处，对查处的典型案件及时进行曝光，实施联合惩戒。</p><p style="margin-top: 0px; margin-bottom: 0px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; clear: both; min-height: 1em; overflow-wrap: break-word !important;"><br style="margin: 0px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; overflow-wrap: break-word !important;"/></p></section><section powered-by="xiumi.us" style="margin: 10px 0px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; color: rgb(34, 34, 34); font-family: -apple-system, BlinkMacSystemFont, Helvetica Neue, PingFang SC, Hiragino Sans GB, Microsoft YaHei UI, Microsoft YaHei, Arial, sans-serif; letter-spacing: 0.544px; white-space: normal; background-color: rgb(255, 255, 255); overflow-wrap: break-word !important;"><section style="margin: 0px; padding: 0px 0px 0px 30px; outline: 0px; max-width: 100%; box-sizing: border-box; overflow-wrap: break-word !important; display: inline-block; min-width: 10%; vertical-align: top;"><section powered-by="xiumi.us" style="margin: 0px 0px -30px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; overflow-wrap: break-word !important; transform: translate3d(-30px, 0px, 0px);"><section style="margin: 0px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; overflow-wrap: break-word !important; display: inline-block; width: 30px; height: 30px; vertical-align: top; overflow: hidden; border-width: 0px; border-radius: 100%; border-style: none; border-color: rgba(118, 178, 124, 0); background-color: rgba(141, 122, 186, 0.3);"><section powered-by="xiumi.us" style="margin: 0px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; overflow-wrap: break-word !important; text-align: justify;"><p style="margin-top: 0px; margin-bottom: 0px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; clear: both; min-height: 1em; overflow-wrap: break-word !important;"><br style="margin: 0px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; overflow-wrap: break-word !important;"/></p></section></section></section><section powered-by="xiumi.us" style="margin: 0px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; overflow-wrap: break-word !important; transform: translate3d(-15px, 0px, 0px);"><section style="margin: 0px; padding: 3px 0px; outline: 0px; max-width: 100%; box-sizing: border-box; overflow-wrap: break-word !important; display: inline-block; min-width: 10%; vertical-align: top;"><section powered-by="xiumi.us" style="margin: 0px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; overflow-wrap: break-word !important; color: rgb(141, 122, 186); text-align: justify;"><p style="margin-top: 0px; margin-bottom: 0px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; clear: both; min-height: 1em; overflow-wrap: break-word !important;"><strong style="margin: 0px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; overflow-wrap: break-word !important;">3 .创新基金监管手段和方式</strong></p></section></section></section></section></section><section powered-by="xiumi.us" style="margin: 0px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; color: rgb(34, 34, 34); font-family: -apple-system, BlinkMacSystemFont, Helvetica Neue, PingFang SC, Hiragino Sans GB, Microsoft YaHei UI, Microsoft YaHei, Arial, sans-serif; letter-spacing: 0.544px; text-align: justify; white-space: normal; background-color: rgb(255, 255, 255); overflow-wrap: break-word !important;"><p style="margin-top: 0px; margin-bottom: 0px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; clear: both; min-height: 1em; overflow-wrap: break-word !important;"><br style="margin: 0px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; overflow-wrap: break-word !important;"/></p><p style="margin-top: 0px; margin-bottom: 0px; padding: 0px; outline: 0px; max-width: 100%; clear: both; min-height: 1em; box-sizing: border-box !important; overflow-wrap: break-word !important;">根据欺诈骗保行为特点，及时改进监管手段。<strong style="margin: 0px; padding: 0px; outline: 0px; max-width: 100%; color: rgb(141, 122, 186); box-sizing: border-box !important; overflow-wrap: break-word !important;">一是</strong>推进标准化信息化建设，利用大数据分析对医疗机构进行筛查，为现场稽核提供数据支持。<strong style="margin: 0px; padding: 0px; outline: 0px; max-width: 100%; color: rgb(141, 122, 186); box-sizing: border-box !important; overflow-wrap: break-word !important;">二是</strong>要坚持专项治理与全覆盖相结合，对涉及医保基金安全的医疗服务行为实行全方位监管，检查要突出重点，对公立医疗机构重点治理乱检查、乱收费、乱用药等“三乱”问题，对民营医疗机构重点治理假病人、假病情、假票据等“三假”问题。<strong style="margin: 0px; padding: 0px; outline: 0px; max-width: 100%; color: rgb(141, 122, 186); box-sizing: border-box !important; overflow-wrap: break-word !important;">三是</strong>以政府购买服务形式常态化引入第三方力量参与监管，组建医保专家库，协助医保部门对定点医药机构进行病历核查、大数据分析、财务审计等，提高基金监管专业化水平。<strong style="margin: 0px; padding: 0px; outline: 0px; max-width: 100%; color: rgb(141, 122, 186); box-sizing: border-box !important; overflow-wrap: break-word !important;">四</strong><strong style="margin: 0px; padding: 0px; outline: 0px; max-width: 100%; color: rgb(141, 122, 186); box-sizing: border-box !important; overflow-wrap: break-word !important;">是</strong>完善医保对医疗服务行为的监控机制，将监管对象由医疗机构延伸至医务人员，将监管重点从医疗费用控制转向医疗费用和医疗服务绩效双控制。<strong style="margin: 0px; padding: 0px; outline: 0px; max-width: 100%; color: rgb(141, 122, 186); box-sizing: border-box !important; overflow-wrap: break-word !important;">五是</strong>建立打击欺诈骗保协同工作制度，针对调查阻力大、专业性强、入户调查取证难的违法违规案件，会同公安部门、市场监管部门、抽调相关临床专家调查取证。</p><p style="margin-top: 0px; margin-bottom: 0px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; clear: both; min-height: 1em; overflow-wrap: break-word !important;"><br style="margin: 0px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; overflow-wrap: break-word !important;"/></p></section><section powered-by="xiumi.us" style="margin: 10px 0px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; color: rgb(34, 34, 34); font-family: -apple-system, BlinkMacSystemFont, Helvetica Neue, PingFang SC, Hiragino Sans GB, Microsoft YaHei UI, Microsoft YaHei, Arial, sans-serif; letter-spacing: 0.544px; white-space: normal; background-color: rgb(255, 255, 255); overflow-wrap: break-word !important;"><section style="margin: 0px; padding: 0px 0px 0px 30px; outline: 0px; max-width: 100%; box-sizing: border-box; overflow-wrap: break-word !important; display: inline-block; min-width: 10%; vertical-align: top;"><section powered-by="xiumi.us" style="margin: 0px 0px -30px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; overflow-wrap: break-word !important; transform: translate3d(-30px, 0px, 0px);"><section style="margin: 0px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; overflow-wrap: break-word !important; display: inline-block; width: 30px; height: 30px; vertical-align: top; overflow: hidden; border-width: 0px; border-radius: 100%; border-style: none; border-color: rgba(118, 178, 124, 0); background-color: rgba(141, 122, 186, 0.3);"><section powered-by="xiumi.us" style="margin: 0px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; overflow-wrap: break-word !important; text-align: justify;"><p style="margin-top: 0px; margin-bottom: 0px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; clear: both; min-height: 1em; overflow-wrap: break-word !important;"><br style="margin: 0px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; overflow-wrap: break-word !important;"/></p></section></section></section><section powered-by="xiumi.us" style="margin: 0px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; overflow-wrap: break-word !important; transform: translate3d(-15px, 0px, 0px);"><section style="margin: 0px; padding: 3px 0px; outline: 0px; max-width: 100%; box-sizing: border-box; overflow-wrap: break-word !important; display: inline-block; min-width: 10%; vertical-align: top;"><section powered-by="xiumi.us" style="margin: 0px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; overflow-wrap: break-word !important; color: rgb(141, 122, 186); text-align: justify;"><p style="margin-top: 0px; margin-bottom: 0px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; clear: both; min-height: 1em; overflow-wrap: break-word !important;"><strong style="margin: 0px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; overflow-wrap: break-word !important;">4.逐步扩大信用监管应用范围</strong></p></section></section></section></section></section><section powered-by="xiumi.us" style="margin: 0px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; color: rgb(34, 34, 34); font-family: -apple-system, BlinkMacSystemFont, Helvetica Neue, PingFang SC, Hiragino Sans GB, Microsoft YaHei UI, Microsoft YaHei, Arial, sans-serif; letter-spacing: 0.544px; text-align: justify; white-space: normal; background-color: rgb(255, 255, 255); overflow-wrap: break-word !important;"><p style="margin-top: 0px; margin-bottom: 0px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; clear: both; min-height: 1em; overflow-wrap: break-word !important;"><br style="margin: 0px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; overflow-wrap: break-word !important;"/></p><p style="margin-top: 0px; margin-bottom: 0px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; clear: both; min-height: 1em; overflow-wrap: break-word !important;">将所有医保主体纳入医保信用监管，根据信用等级进行分级分类监管。<strong style="margin: 0px; padding: 0px; outline: 0px; max-width: 100%; color: rgb(141, 122, 186); box-sizing: border-box !important; overflow-wrap: break-word !important;">一是</strong>拓宽医保信用监管系统功能，与医保智能监控系统、医保核心业务系统等多系统进行数据对接，形成不同部门间数据共享、结果互认、力量叠加的多场景运用，实现信用评价信息自动归集和预警信息的多向推送。<strong style="margin: 0px; padding: 0px; outline: 0px; max-width: 100%; color: rgb(141, 122, 186); box-sizing: border-box !important; overflow-wrap: break-word !important;">二是</strong>完善涵盖医疗机构、零售药店、医保医师、参保人员、药品耗材经销商的基金监管信用评价指标体系，丰富信用主体信用档案库。<strong style="margin: 0px; padding: 0px; outline: 0px; max-width: 100%; color: rgb(141, 122, 186); box-sizing: border-box !important; overflow-wrap: break-word !important;">三是</strong>要在医保信用体系建设中将人民群众的满意度作为信用体系的重要内容。通过建设参保满意度调查系统，细化基础信息指标、功能指标、结果指标和维度指标的医保信用综合满意度测评标准，督促医疗机构持续改进医疗服务质量和医保服务水平。<strong style="margin: 0px; padding: 0px; outline: 0px; max-width: 100%; color: rgb(141, 122, 186); box-sizing: border-box !important; overflow-wrap: break-word !important;">四是</strong>将信用评价结果与预算管理、检查稽核、协议管理等相关联。建立跨部门联合奖惩机制，依法依规实行守信联合激励和失信联合惩戒，引导医保信用主体自觉遵规守法。<span style="margin: 0px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; overflow-wrap: break-word !important; color: rgb(160, 160, 160);">（ZGYB-2022.04）</span></p><p style="margin-top: 0px; margin-bottom: 0px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; clear: both; min-height: 1em; overflow-wrap: break-word !important;"><br style="margin: 0px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; overflow-wrap: break-word !important;"/></p></section><section powered-by="xiumi.us" style="margin: 0px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; font-family: -apple-system, BlinkMacSystemFont, Helvetica Neue, PingFang SC, Hiragino Sans GB, Microsoft YaHei UI, Microsoft YaHei, Arial, sans-serif; letter-spacing: 0.544px; text-align: justify; white-space: normal; background-color: rgb(255, 255, 255); color: rgb(137, 137, 137); font-size: 14px; overflow-wrap: break-word !important;"><p style="margin-top: 0px; margin-bottom: 0px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; clear: both; min-height: 1em; text-align: center; overflow-wrap: break-word !important;"><strong style="margin: 0px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; overflow-wrap: break-word !important;">来源</strong></p><p style="margin-top: 0px; margin-bottom: 0px; padding: 0px; outline: 0px; max-width: 100%; box-sizing: border-box; clear: both; min-height: 1em; text-align: center; overflow-wrap: break-word !important;">中国医疗保障</p></section><p></p><p><br/></p><link rel="stylesheet" href="//www.dafuping.cn/source/plugin/wcn_editor/public/wcn_editor_fit.css?v134_I0n" id="wcn_editor_css"/>
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