绩溪：医保监管“探照灯”照亮基层村卫生室
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<div class="ce-paragraph cdx-block ce-paragraph--{data.alignment}">来源：绩溪县人民政府(办公室) </div>
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<div class="ce-paragraph cdx-block ce-paragraph--{data.alignment}">村卫生室作为农村地区最便捷、最实用的医疗服务网点，是守护农民健康的第一道防线。为筑牢这一基础医疗堡垒，保障医保基金的每一分钱都切实用于群众所需，绩溪县医保局坚持规范与支持并重，推动村卫生室在医保政策框架内规范运行、优化服务，切实发挥健康“守门人”作用，实现医保基金安全、高效使用，让广大农村居民享有更加公平、可及、优质的医疗保障。</div>
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<div class="ce-paragraph cdx-block ce-paragraph--{data.alignment}">一、数据筛查，精准定位问题</div>
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<div class="ce-paragraph cdx-block ce-paragraph--{data.alignment}">县医保局依托医保信息平台，建成覆盖全县69家村卫生室的智能监控系统。该系统今年以来对各村卫生室自动捕捉并推送疑似问题数据261条，涉及疑似违规金额2757.22元，为实施靶向监管提供了数据支撑。同时，通过对村卫生室城乡居民“两病”门诊、普通门诊等数据的深度分析，梳理出“非‘两病’用药”、“重复结算”、“一般诊疗费超收”等8大类风险点，共1355条，涉及疑似违规金额9130.07元。</div>
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<div class="ce-paragraph cdx-block ce-paragraph--{data.alignment}">二、问题导向，督促限时整改</div>
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<div class="ce-paragraph cdx-block ce-paragraph--{data.alignment}">针对系统筛查出的问题线索，县医保局建立“线上预警+线下核查”双轨机制。线上实时推送预警信息，要求涉事村卫生室限期说明；线下组织稽核人员开展现场检查，通过到村卫生室一线核对处方、病历、结算单据和药品库存，确保“四吻合”，准确认定问题性质。对核实违规的行为，同步指导制定整改措施并限时落实。今年以来，现场检查共发现10类问题，追回违规使用医保基金3997.85元，扣除违约金399.8元。</div>
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<div class="ce-paragraph cdx-block ce-paragraph--{data.alignment}">三、整改跟踪，实现长效闭环</div>
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<div class="ce-paragraph cdx-block ce-paragraph--{data.alignment}">县医保局出台《关于建立定点医疗机构违法违规使用医保基金问题整改跟踪机制的通知》，构建“发现问题—督促整改—回头看”全流程闭环管理体系。对存在问题村卫生室开展不定期“回头看”，重点检查整改落实及复发情况。对整改不力、逾期未改的，采取警示约谈、通报批评等措施。截至目前，该机制已推动整改问题15个，整改完成率100%，问题复发率显著下降。</div>
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<div class="ce-paragraph cdx-block ce-paragraph--{data.alignment}">通过一系列环环相扣的监管举措，绩溪县医保局不仅牢牢守住了医保基金的安全底线，也推动了村卫生室诊疗服务持续规范，让医保“救命钱”在阳光下运行，真正惠及广大农村居民。</div>
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