To promote health insurance professional management
Improve the medical risk management and control measures

One is to change the traditional mode of settlement of claims, claim review extended forward. The case of large payment that occur, not only for supplementary medical part of the audit, but also the cost of basic medical review section, enhanced claims audit initiative. Second, with medical insurance information system of the hospitals insured medical expense, to conduct real-time monitoring, once the abnormal medical expenses exceed a certain amount of clues or warning line of cases the cost in advance to take the initiative early warning and rapid intervention to prevent unreasonable payment risk. Third, actively carry out supervision and inspection of medical institutions, and strengthen risk management in medical procedures, change from passive to active ex-post cost of auditing the whole process of monitoring. The formation of health care services inspection team (part of the main hospital stationed in hand), in support of health insurance sector to strengthen the insured seeking behavior of inspections, found someone else's medical care and other irrational medical practices, timely and doctors, hospitals, communication solution. 4 is in line with the Government investigate irregularities in the implementation of designated hospitals for examination and evaluation system, standardize medical care. In the inspection and audit process, the verified irrational medical practices, which reported the formation of the proposed health insurance sector, after deducting the reasonable medical expenses at the same time, by the health insurance sector to punish violations, and on a regular basis in conjunction with health insurance sector to designated hospitals for medical services specification examine and evaluate the situation, the failure and not by the rectification of successful applicants will be eligible to cancel their fixed-point. 5 is transferred to assist in referral management, and effectively prevent the risk of off-site medical treatment. The use of PICC Health co-operation throughout the country hospital network, to be insured off-site medical treatment authorized by the Medicare Center for approval and referral assistance, and its off-site to monitor doctor behavior, both to some extent alleviated the insured "a doctor is difficult" issue, but also help the government has increased the cost of the remote control for medical treatment.

(D) the establishment of medical insurance departments, hospitals and corporate integrated information platform for

According to the Government commissioned a business and interface matching the characteristics of basic health, human health, development of a professional insurance medical insurance management information systems to support the company's core business systems and social security sectors, the data exchange between designated hospitals to achieve insured care information, drug data and cost of billing and other information timely and accurate data sharing, implementation and designated hospitals for direct settlement and paid simultaneously with the basic health, both to improve timeliness of claims, but also convenient for the insured.

(E) active in the health management services

Give full play to health management of professional advantage, for some serious illness, especially chronic diseases (hypertension, diabetes, etc.) and provide patients with health education, health counseling, SMS alerts and other services to help the insured to form good habits, reduce the incidence of disease and improve health.

Through all these initiatives, the contractors were commissioned by the Government for a healthy business, operating mode and gradually improved economic and social benefits to gradually appear, and achieving the insured, government, medical institutions and professional health insurance companies, four win-win situation, its effectiveness lies in the following four areas:

One is to raise the people's standard of medical care. Advantage by leveraging professional management and effective control of payment risks, without increasing the burden of financing the government and residents of the situation, raising the insured amount of medical care personnel to assist the Government to ease the insured population, "impoverished by hospitalization, fell back into poverty due to illness" problems, promoting social harmony and stability.

Second, is to improve the Government's medical and social security matters in management efficiency and service levels. Commissioned by the Government do a good job in the supplementary medical at the same time, will extend a number of professional management techniques applied to basic medical field, to assist the Government improve the basic health care management efficiency and service levels, and to some extent, eased the expansion of government departments, staffing and financial expenses increased pressure.