CCTV News: Medical insurance funds are the "medical money" and "life-saving money" for the people. In 2024, the Central Committee of the China Democratic League submitted a "Proposal on Building a "big data + AI" regulatory system and improving the supervision level of medical insurance funds" to the CPPCC. The "Proposal" states that intelligent medical insurance supervision should be promoted and the application of big data in fund supervision should be strengthened. Based on the national unified medical insurance information platform, the National Medical Insurance Administration continues to promote the construction of medical insurance informationization, carry out intelligent review and monitoring of medical insurance funds, big data screening and analysis applications, promote the "shifting of the barriers" forward, and continuously improve the professionalization and intelligence level of fund supervision, and protect the safety of funds.
In a community health service center in Jinan, Shandong, doctor Wang Ruilan prescribed a drug to a female insured person, a risk warning prompt popped up in the medical insurance intelligent supervision system, which may have violated the rules.
Using an intelligent supervision system, setting up reminders such as reasonable use of drugs and drug policy restrictions in designated medical institutions, and realizing automatic interception of rigid constraint violations in advance is a typical case of intelligent medical insurance fund supervision.
How to supervise the "life-saving money" medical insurance fund has always been one of the focus of attention of all parties. In this regard, the Central Committee of the China Democratic League and the Henan Provincial Committee of the China Democratic League jointly conducted various forms of special research.
Based on the research, after extensive research and demonstration, soliciting opinions and suggestions, holding special research seminars, the Central Committee of the China Democratic League finally formed the "Proposal on Building a "big data + AI" regulatory system and improving the supervision level of medical insurance funds."
Promoting intelligent fund supervision has always been a key topic for the medical insurance department. At present, all coordinated areas have implemented and applied the intelligent supervision subsystem of the National Medical Insurance Information Platform, and gradually built a fund security prevention and control mechanism for all aspects of supervision before, during and after.
After passing the screening of rigid conditions in advance, a large amount of settlement information will still be gathered at the medical insurance center to wait for settlement every day. In-process review means to implement intelligent supervision before settlement through more accurate and detailed rules. In Hangzhou, Zhejiang, after the on-site audit rules are launched, the operation effect will be continuously monitored, the linkage between audit rules and clinical practice will be strengthened, and the timely improvement and optimization will be improved.
In addition, the "Proposal" mentioned that it is necessary to further improve the nationwide unified intelligent audit and monitoring system, solve the overall, targeted and agile problems in supervision, and achieve high-efficiency and low-cost supervision. At the National Health Insurance Administration, staff showed reporters the regulatory system for the precise positioning of fraudulent insurance fraud to reporters.
Li Jun, Fund Supervision Department of the National Health Insurance Administration, said: "For example, the hospitalization screening model is mainly aimed at some gang-like violations. For example, today a wave of people were hospitalized in one place, and after a period of time, they were hospitalized in another place. These people were in and out. (Reporter: If this was when it was used to screen manually, would it be difficult to find it?) If it was the previous model, it was actually difficult to find the data of a single hospital, especially across coordinated areas, across hospitals, and across provinces. It was difficult to find it."
In 2024, among the more than 1,800 clues found through hospitalization model screening, medium and high-risk clues were basically found to have problems. Big data models can accurately capture and crack down on fraudulent insurance behaviors.
Gu Rong, Director of the Fund Supervision Department of the National Medical Insurance Administration, said: "The suggestions and proposals of representatives and deputies fully reflect the concern and importance of all sectors of society for the supervision of medical insurance funds. Now, in the supervision of medical insurance funds such as flight inspections and crackdown on fraud and insurance fraud, big data and intelligent supervision have played an important role and provided strong support. In 2024, we recovered nearly 600 million yuan of medical insurance funds through abnormal hospitalization and reselling medical insurance drugs, and recovered nearly 100 million yuan of medical insurance funds through big data screening clues such as men and women's examinations, men and women's medications, and glycated hemoglobin. We recovered 3.1 billion yuan of medical insurance funds through intelligent supervision subsystems."
