"Internet" medical service prices and medical insurance payment policy guidance issued!

Release time:


Today (August 30), the National Health Insurance Bureau issued guidance on improving the price of "Internet" medical services and medical insurance payment policies. The opinion pointed out that "Internet" medical services are medical institutions at all levels and types. Under the premise of compliance with laws and regulations, offline existing medical services will be carried out and extended online. "Internet" medical service prices, into the current policy system of medical service prices unified management.

The following is the original text:

National Medical Security Bureau on the improvement of "Internet" medical services

Guidance on pricing and health insurance payment policies

Medical Insurance 2019 No. 47

The medical security bureaus of all provinces, autonomous regions, municipalities directly under the Central Government and Xinjiang Production and Construction Corps:

In order to implement the spirit of the General Office of the State Council "Opinions on Promoting the Development of" Internet Medical Health "" (Guo Ban Fa [2018] No. 26) and the "Notice on Issuing the Key Tasks for Deepening the Reform of the Medical and Health System in 2019" (Guo Ban Fa [2019] No. 28), and improve the price and payment policies for "Internet" medical services, the following opinions are hereby put forward.

General 1. requirements

(I) guiding ideology.

Guided by Xi Jinping's thoughts on socialism with Chinese characteristics in the new era, focusing on people's health, adapting to the development of "Internet medical health", reasonably determining and dynamically adjusting prices and medical insurance payment policies, and supporting the "Internet" in realizing the cross-regional flow of high-quality medical resources, Promoting medical services to reduce costs, increase efficiency and fairness, improve patients' medical experience, and reconstruct the competitive relationship in the medical market.

(II) basic principles.

One is to deepen the "release of tube clothing". Adhere to the combination of market formation, government regulation and social co-governance, establish an open, flexible and multi-party price formation mechanism, stimulate the vitality of the medical market and guide the provision of appropriate services.

The second is classified management. Adapt to the operation and development law of the "Internet", and formulate operational price and payment policies for different service subjects, objects and content.

The third is to encourage innovation. For new technologies and new models that rely on the "Internet" to significantly improve cost efficiency and better meet multi-level medical needs, more relaxed development space will be given.

The fourth is coordinated development. Implement fair pricing and payment policies for online and offline medical services to promote the coordinated development of online and offline services.

(III) the main idea.

"Internet" medical services are medical institutions at all levels and types. Under the premise of compliance with laws and regulations, offline existing medical services are carried out and extended online. "Internet" medical service prices, into the current policy system of medical service prices unified management. Eligible "Internet" medical services, in accordance with the principle of online and offline fairness supporting medical insurance payment policies, and according to the characteristics of the service to improve the agreement management, settlement process and related indicators. Actively adapt to the development of new business formats such as the "Internet", improve the level of informatization and intelligence of medical service price monitoring and supervision, guide the reconstruction of medical market competition, and explore new mechanisms for opening and diversifying medical service prices under new technological conditions.

2. Improve the "Internet" Medical Service Price Project Management

(I) project policies are classified and managed according to the nature of operation of medical institutions.

For the "Internet" medical services carried out by non-profit medical institutions in accordance with the law, the medical security department mainly manages according to the project, and the unapproved medical service price items shall not charge patients. For-profit medical institutions provide "Internet" medical services carried out in accordance with the law, and may set up their own medical service price items. Internet hospitals apply the corresponding price item policy according to the form of ownership and the nature of operation of their registration.

(II) project access to the province-based implementation of hierarchical management.

Medical service price items are managed at the provincial level and at the national, provincial and municipal levels. The National Medical Security Bureau is responsible for standardizing the principles of project initiation, project name, service connotation, pricing unit, pricing instructions, coding rules, etc., and guiding the provincial medical security departments to do a good job in medical service price projects. Each provincial medical security department is responsible for setting up medical service price items applicable to the region according to the development of medical technology and the actual situation of the region. Medical institutions will carry out existing offline projects online. If they apply for project establishment fees, they will be accepted by the municipal medical security department. If they meet the access conditions, they will be submitted to the provincial medical security department for centralized review and decision-making.

(III) clarify the basic conditions for project access.

The establishment of "Internet" medical service price items should meet the following basic conditions at the same time: first, it should belong to services that are permitted by the competent department of the health industry to be carried out in the way of "Internet", with clear clinical paths and clear technical specifications; Second, direct services should be provided to patients. Third, the service process should be completed remotely through media such as the Internet. Fourth, the service should be able to realize the function of the same items offline; fifth, the service should have a substantial effect on the diagnosis and treatment of diseases. No additional items shall be added in the form or name of changing the way of expression, splitting the connotation of services, adding non-medical steps, etc.

(IV) clearly not as a medical service price item.

Services that occur only between medical institutions and medical institutions, between medical institutions and other institutions, and are not directly oriented to patients; services provided by medical institutions to patients that are not part of diagnosis and treatment activities; and services provided by non-medical personnel, not as medical service price items, including but not limited to remote surgery guidance, remote rounds, medical consultation, education and training, scientific research follow-up, data processing, medical identification, health consultation, health management, convenience services, etc.

3. a sound "Internet" medical service price formation mechanism

The (I) price policy shall be classified and managed according to the public and non-public.

Public medical institutions provide "Internet" medical services, which are mainly regulated by the government. The medical security department gives guidance on the upper limit of the project charging standard. Public medical institutions charge service fees according to the standard that does not exceed the price announced by the medical security department; meet personalized, "Internet" medical services with high-level needs, and "Internet" medical services provided to foreign and overseas, implement the requirements of special medical scale control and market adjustment price policy. If the price is regulated by the market, the public medical institution shall comprehensively consider the service cost, patient demand and other factors, independently determine the charging standard and floating range, and inform the local medical security department in writing.

Non-public medical institutions provide "Internet" medical services, and the price is regulated by the market.

(II) charging methods should reflect the characteristics of cross-regional services.

Public medical institutions provide "Internet" medical services. The price includes the complete cost of a project. According to the principle of localization, it is set by the public medical institution or the provincial medical security department in the region where it is located. Medical security departments and medical institutions shall not set unfair price standards due to different service objects and service areas.

Patients receive "Internet" medical services and pay for the price of the items performed by the service invitee. If the "Internet" medical service involves multiple subjects such as the inviter, the invitee and the technical supporter, or involves different departments of the same subject, the parties shall negotiate and determine the distribution relationship.

The (III) medical insurance department shall set and adjust the price to implement provincial management.

Provincial medical security departments are responsible for formulating and adjusting the prices of "Internet" medical services provided by public medical institutions. For the newly launched "Internet" medical services, the price can be set by the provincial medical security department or the trial price can be determined by agreement with medical institutions. When a medical institution applies for a project, it shall, in accordance with the provisions of the provincial medical security department, simultaneously submit price proposals, cost calculation results, economic evaluation reports, comparative analysis with similar projects offline and other information. At the end of the trial period (generally no more than two years), the price policy will be further clarified on the basis of evaluating the service effect and cost income.

(IV) setting adjustment prices should maintain a reasonable price comparison online and offline.

When formulating and adjusting the price of "Internet" medical services, the provincial medical security department should maintain a reasonable price comparison of similar services online and offline: first, the price of online and offline services should match the service utility, maintain a reasonable price comparison relationship and price level, and reflect the equal emphasis on incentive services and prevention of abuse; second, the price of online and offline services should match the degree of economic improvement, so that online services can be more conducive to saving the overall cost of patients than traditional medical treatment, and third, the price of online and offline services should match the difference in the necessary costs, reflecting the common cost of medical services and the additional cost of the "Internet.

(V) refine the price policy according to the characteristics of various types of services.

First, if public medical institutions provide inspection and inspection services and entrust a third party to issue conclusions, the fees will be implemented according to the price of the entrusting party's offline inspection and inspection service items, and will not be charged separately according to remote diagnosis. Second, public medical institutions carry out Internet follow-up visits and provide services by different levels of medical personnel, all of which are charged according to the prices of general outpatient consultation items. Third, public medical institutions rely on the "Internet" to provide family doctor services, provide services and settlement fees in accordance with the contracted content and standards of the service package, and do not charge or add fees due to changes in service methods.

(VI) fully protect the reasonable and legitimate price rights and interests of patients.

All kinds of subjects provide "Internet" medical services, and the charges should be based on informed consent and legal compliance, follow the principles of fairness, legality, and good faith, and reasonably set and adjust prices within the scope permitted by the policy, and be clear and clear The way is announced. The medical security departments in all regions should strengthen the supervision of the fund. For medical institutions that have untrustworthy behaviors such as compulsory services, decomposition services, providing services at unfair prices, and falsely reporting prices, they should adopt methods such as interviews and warnings, and require rectification to restrain them, and are suspected of violations of laws and regulations. In case of violation of regulations, clues to relevant issues should be transferred to the law enforcement department for inspection in a timely manner.

4. defines the medical insurance payment policy for "Internet" medical services.

(I) determine the scope of health insurance payments.

If the "Internet" medical services provided by designated medical institutions are the same as the offline medical services within the scope of medical insurance payment, and the corresponding public medical institutions charge prices shall be included in the scope of medical insurance payment after the corresponding filing procedures and paid in accordance with the regulations. The "Internet", which belongs to the brand-new content, implements the basic medical services adjusted by the government. The provincial medical security departments shall, in accordance with the regulations, comprehensively consider the clinical value, price level, medical insurance payment ability and other factors to determine whether it is included in the scope of medical insurance payment.

(II) improve the management of medical insurance agreements.

Medical security departments at all levels should reasonably determine the total amount control index according to the characteristics of "Internet" medical services, improve the service agreement of designated medical institutions, adjust the medical insurance information system, optimize the settlement process, strengthen the supervision of medical services, and support designated medical institutions to provide standardized, convenient, high-quality and efficient medical services relying on the "Internet. For designated medical institutions that have price dishonesty, fraud and insurance fraud, etc., they shall be included in the scope of agreement breach and dealt with in accordance with the provisions.

5. strengthening organization implementation

(I) grasp the implementation and ease contradictions.

The medical security departments of all provinces (autonomous regions and municipalities) shall, in accordance with the requirements of this opinion, sort out and adjust the "Internet" medical service prices and medical insurance payment policies in a timely manner, standardize price items, ease accumulated price contradictions, and effectively link up price and payment policies. Involving the responsibilities of health and market supervision departments, they should fully listen to opinions and suggestions, do a good job of communication and cooperation, and hand over clues to problems in a timely manner.

(II) strengthen price monitoring and follow-up assessment.

The medical security departments of all provinces (autonomous regions and municipalities) should focus on public medical institutions, strengthen the daily monitoring and supervision of medical service prices, and report new situations and new problems in their work in a timely manner. After the change of offline project service form, the cost fluctuates greatly, it is necessary to carry out investigation in time, dynamically adjust or guide public medical institutions to adjust prices in time.

(III) do a good job in policy interpretation and public opinion guidance.

Combining the new laws and new characteristics of "Internet" medical services, timely and accurately interpret price and payment policies, reasonably guide social expectations, actively respond to social concerns, and strive for the understanding and support of all sectors of society. Gather consensus from all parties, guide medical staff to actively participate, create a good environment for reform, and ensure the smooth progress of reform.

National Medical Security Bureau