国家医保局：全国各统筹地区2025年底前实现即到

国家医保局今日发布《关于全面推进医保资金即时结算改革扩大规模、提高质量的通知》，要求全国各协调地区在2025年底前开展即时结算。国家医保局要求全面推进即时结算改革。到2025年底，全国所有协调地区都要实现即时结算。到2026年底，实时结算资金占地方医保基金月结算资金的80%以上。结算资金涵盖职工医疗保险基金（含生育保险）和城乡医疗保险基金。条件允许的，可以探索将大病保险基金、医疗救助基金等纳入即时结算范围。定居者资金用于支付普通门诊、慢性疼痛门诊、住院、分娩、药店购药等医疗费用。可以逐步探索将其他领域的医疗费用纳入即时结算范围。到2026年底，定点医疗机构即时结算比例达到80%以上。推动二级及以上定点医疗机构全部缴费，鼓励一级及未指定定点医疗机构纳入即时结算范围。符合条件的定点零售药店将逐步纳入即时经营机构范围。指导省医保部门协调本地区定点医疗机构原则上次月10日前申报医疗费用。各地要进一步规范实时结算t process, use information technology to improve the efficiency of real-time settlement, shorten the settlement cycle, and allocate settlement funds no more than 20 working days from the day after the application deadline for designated medical institutions, and strive to allocate them before the end of the next month. Force the application review cycle for special individual cases and further improve the efficiency of medical insurance fund settlement and allocation. All localities can reasonably determine the proportion of real-time settlement allocationsbased on the current year's insurance fund budget, last year's medical insurance fund expenditures, etc. Strengthen the review and control mechanism.各地要严格把握分析门槛，避免资金安全面临风险。 Relying on the National Unified Medical Insurance Platform Platform, intelligent analysis of medical costs uploaded by designated medical institutions is fully covered, and doubtful 数据需接受人工审核。按一定比例进行人工抽查。违规费用按月扣除。健全考核监督机制。将实时结算纳入定点医疗机构医疗保障服务协议管理范围，做好费用分析、结算、午睡考核等工作。将实时结算纳入内控管理范围，重点关注企业财务核对和财务管理、资金拨付准确性、日（周、十日）拨付与月审核结算衔接等问题。完善风险预警机制。加强定点医疗机构异常实时结算数据监测。出现可能影响医保基金运行安全的情况时，可进行约谈提醒、暂停扣除必要时确保医保基金安全。定点医疗机构暂停或者终止医疗保障服务协议等影响资金安全的，必须及时暂停或者终止即时协议。 。