On August 31, it was learned that the “Chongqing Medical Insurance Fund Supervision Credit Management Measures” (hereinafter referred to as the “Measures”) will be officially implemented on September 1. The medical insurance administrative department will implement a credit-based hierarchical supervision system for entities using the medical insurance fund in Chongqing. Hospitals, pharmacies, and insured individuals will each have a medical insurance fund supervision credit file.
The introduction of the “Measures” aims to better manage and utilize the public’s medical and life-saving funds. The applicable credit entities refer to natural persons, legal persons, and unincorporated organizations with full civil capacity, which fulfill statutory duties, legal obligations, or agreed obligations in the use of the medical insurance fund. These are mainly divided into institutional and individual categories. Institutional categories mainly include designated medical institutions and designated retail pharmacies for medical insurance. Individual categories mainly include insured individuals and medical personnel such as doctors, nurses, pharmacists, and technicians involved in medical insurance fund usage.
Each credit entity will have a medical insurance fund supervision credit file, which includes basic information, trustworthy information, untrustworthy information, credit evaluation results, and historical credit information. Based on this information, the medical insurance department will conduct dynamic evaluations and determine the credit等级 for medical insurance fund supervision according to the evaluation results.
What is the purpose of these credit等级? According to the “Measures,” the credit evaluation of designated医药机构 adopts a points system with a maximum score of 100 points, a baseline of 0 points, and an annual cycle from January 1 to December 31. The credit等级 are divided into five levels: Level A for scores of 90 points or above, Level B for 80–90 points (including 80), Level C for 70–80 points (including 70), Level D for 60–70 points (including 60), and Level E for below 60 points.
Level E is the lowest tier, and the “Measures” also specify circumstances that directly result in being classified as Level E. These include seven situations such as having定点服务协议 terminated due to violations, being suspended for two consecutive years, refusing to correct or implement处理处罚 decisions after penalties, obstructing or refusing to cooperate with supervision and inspections, and falsifying information in credit等级 evaluations.
Credit entities will be subject to incentives or penalties in collaboration with relevant departments. For example, designated医药机构 rated as Level A will have reduced frequency of routine on-site inspections and priority in piloting new medical insurance policies under equal conditions. Designated医药机构 rated as Level E will face penalties such as increased frequency of random inspections and withholding of advance payments.
For失信参保人 rated as Level D, penalties will include conducting medical insurance legal education, re-examining their historical享受待遇情况, settlement status, and eligibility for benefits, and publicly disclosing违法 and失信 information within legal limits.
