"After the implementation of the instant settlement reform, the hospital can receive a proportion of the inpatient medical insurance fund that occurred on the previous day every day, which alleviates the pressure of the hospital to pay funds in advance and gives impetus to the sustainable development of the hospital." Anhui provincial People's Congress representative, Huaibei City People's Hospital President Liu Yonggang praised. The instant settlement praised by President Liu is a new model of medical insurance fund settlement reform implemented by the Anhui Provincial Medical Insurance Bureau and deployed by the State Medical Insurance Bureau since January 1, 2025.

"T+n" becomes "T+1"

In the past, the medical insurance fund settlement of medical institutions has been a "post-payment system", that is, insured patients only pay personal out-of-pocket expenses when discharged, and the medical insurance reimbursement part needs to be summarized on a case-by-case basis in the month before the 15th of the next month to apply for payment to the medical insurance agency; After the medical insurance agency accepts it, it will complete the review, allocation and other procedures within 30 working days. There is a lag in the disbursement of this fund, and a medical insurance payment usually takes 60 days from the patient's discharge to the hospital account. In case of abnormal settlement, communication and reconsideration are needed, sometimes it takes longer to arrive at the account, which is not conducive to the flow of hospital funds.

In order to solve this problem, the National Healthcare Security Administration requires provinces to actively explore a new model of instant settlement of hospital medical insurance funds. Under the care and guidance of Zhang Ke, secretary of the Party Group and director of the National Medical Insurance Bureau, Anhui Province innovated the medical insurance fund settlement mechanism of "daily allocation, monthly settlement and annual settlement", that is, when patients handle the discharge settlement, the business subsystem of the medical insurance information platform will capture the medical insurance settlement information of patients in real time and automatically allocate 60% of the medical insurance fund payment amount. After the implementation of instant settlement, the payment time limit of the medical insurance fund has been reduced from the usual 60 days to one day, greatly shortening the payment cycle of the medical insurance fund to medical institutions, easing the pressure on medical institutions to pay funds in advance, and improving the efficiency of the medical insurance fund. According to the expenditure of the provincial inpatient medical insurance fund in 2024, more than 17 billion yuan of medical insurance fund will be paid to designated hospitals 2 to 3 months in advance.

Blade inward change process

To promote the immediate settlement of medical insurance funds, it is not a technical problem that is difficult to change, but an ideological concept. A large amount of funds are deposited in the special medical insurance accounts, just like "money in the hand can not be squeezed out of the water." After "post-payment" becomes "cash payment", the cash flow problem can be significantly solved for designated hospitals.

Anhui Provincial Medical Insurance Bureau adheres to the knife edge inward, self-revolution, provincial and municipal linkage to set up a special work class, systematically comb the fund settlement process, and find an innovation path. In accordance with the principle of "enabling the hospital without obstructing", the settlement business rules and fund approval process are adjusted, and on this basis, the medical insurance information platform is optimized and upgraded, and the "information flow" of data is smooth, so that the hospital does not need to transform HIS system, increase hospital costs, and increase the workload of hospital finance and other departments. Adhering to the concept of "can be fast, can not be slow, can not be delayed", in less than 2 months, the transformation of the province's medical insurance settlement model and the rapid landing of reform measures have been achieved.

Data empowerment

The average daily settlement of medical insurance hospitalization expenses in Anhui province is about 34,000 people. In the face of massive data, it is impossible to realize instant settlement by traditional manual collection, summary and disbursement. Want to instant settlement automatic, no influence, we must rely on information support and big data support.

The first is to transform the internal related subsystems of the medical insurance information platform to achieve seamless interoperability of the medical insurance settlement business, intelligent supervision, business and financial integration, operation monitoring and other systems and expand the whole process functions involved in instant settlement. The second is to optimize the current data interaction interface and dictionary between the medical insurance information platform and the hospital HIS system. When the patient completes the discharge settlement at the hospital window, the medical insurance information platform can capture the detailed data of the Medical Insurance Settlement List in real time, carry out logical classification and calculation by automatic insurance types according to the proportion of instant settlement payment, and then transmit the details of payable funds to the financial integration subsystem of medical insurance business in real time. This process is completed in "milliseconds" at the time of patient discharge settlement. Third, fully unblock the link between the medical insurance information platform and the bank payment management platform. Through the "bank-enterprise (medical bank) direct connection" function, the medical insurance business financial integration system will issue the payment "instruction" to the local medical insurance fund payout bank, and the bank will allocate the funds to the hospital online according to the payee account information maintained in advance. The fourth is to develop a special module of real-time settlement "real-time monitoring", which automatically gathers and displays data such as the number of medical institutions' access, the number of settlement payable details, the number of funds payable, and the number of funds immediately disbursed every 10 minutes at the provincial level, and tracks each cost in a closed-loop manner to effectively control fund risks.

Departments work together to promote reform

The reform of instant settlement of medical insurance fund is inseparable from the cooperation of medical insurance department, financial department, financial institution and medical institution. Anhui Provincial Health Insurance Bureau took the initiative to contact the provincial finance department, door-to-door consultation on the reform plan, and won strong support from the financial department; Communicate with financial institutions face to face to discuss the details of the disbursement, ensure that the fund is disbursed to medical institutions in a timely manner after receiving the disbursement order from the medical insurance department, and provide the disbursement business receipt; Talk and discuss with medical institutions, carry out roadshows on the functions of the instant settlement system, so that medical institutions can understand and support the reform of instant settlement. On December 10, 2024, the Anhui Medical Insurance Bureau, together with the provincial Department of Finance, took the lead in issuing the Notice on Pilot Reform of Basic Medical Insurance Settlement Mode and its implementation plan, clarifying that the financial department is responsible for the timely and full allocation of medical insurance fund reserves and daily medical insurance settlement funds; Medical institutions are responsible for monthly settlement reconciliation, expense confirmation, etc.; Financial institutions are responsible for timely and accurate disbursement of funds. With the cooperation of various departments, the reform of instant settlement of Anhui medical insurance fund has been promoted rapidly.

In the next step, the Anhui Provincial Medical Insurance Bureau will further implement the spirit of the National Medical security Work Conference, make good use of the policy toolbox of medical insurance fund advance and settlement, actively promote the reform of immediate settlement, direct settlement and synchronous settlement of medical insurance fund, crack the problem of poor capital flow in the pharmaceutical industry, and improve the cash flow level of medical institutions and the whole industry. Better enable the healthy development of the pharmaceutical industry.