To deepen the refined management of medical insurance and establish a collaborative working mechanism between hospitals and departments, thereby ensuring the precise implementation of medical insurance policies, Nanjing Zijin Hospital convened the “Inaugural Meeting for the Establishment of Medical Insurance Liaisons and the First Professional Training Session” on March 21, 2025. The meeting was chaired by the director of the Medical Insurance Office, with attendance from the hospital president, the director of the Jiangning Regional Division, the deputy director of the Nursing Department, several ward directors, and medical insurance liaisons from all clinical, nursing, and technical departments across the hospital. The successful convening of this event marks the official formation of the hospital’s first-ever team of medical insurance liaisons and ushers in a new chapter in enhancing the efficiency of medical insurance services.

I. Address by the Leadership: Anchoring the Vision, Strengthening Accountability and Responsibility

In her address, President Ge Jiangping provided a thorough analysis of the current landscape of healthcare insurance reform, emphasizing: “The national drive to deepen medical‑care reform has raised the bar for health‑insurance administration. Medical personnel represent the ‘last mile’ in implementing these policies and serve as the cornerstone for safeguarding patients’ rights.” She further noted that the reform of health‑insurance payment models presents both challenges and opportunities for healthcare institutions, urging the entire hospital to advance the following health‑insurance initiatives with a strong sense of responsibility and mission:

1. Policy Alignment: Medical insurance liaisons must be thoroughly familiar with relevant medical insurance regulations to ensure the accurate and consistent implementation of departmental medical insurance policies.

2. Service Enhancement: Guided by patient needs, we will streamline medical insurance service processes and enhance the patient experience.

3. Collaborative Coordination: Establish an efficient communication mechanism between clinical departments and the Medical Insurance Office, fostering a hospital-wide, unified approach to medical insurance management.

4. Expanding Impact Through Key Personnel: Medical insurance liaisons are appointed annually and rotate regularly across departments, fostering the standardized use of medical insurance funds among frontline clinical staff and safeguarding patients’ rights and interests.

Dean Ge particularly emphasized that medical insurance liaisons serve as a “bridge and link,” and must be rooted in the clinical frontline, leveraging their professional expertise to advance the hospital’s compliant development while also promoting appropriate diagnosis and treatment among physicians, nurses, and technical staff.

II. Policy Analysis: Seizing Trends and Strengthening the Business Foundation

1. The director of the Medical Insurance Office conducted a specialized training session on the “Service Agreement for Designated Medical Institutions under the Nanjing Municipal Medical Insurance System,” systematically expounding on three core components:

(1) Rights, Responsibilities, and Obligations: Clearly define the mutual responsibilities of the higher-level medical insurance authorities and designated medical institutions; emphasize that hospitals must strictly comply with the terms of service agreements and optimize the efficiency of fund utilization, while strengthening risk prevention and control mechanisms to ensure the security of medical insurance funds.

(2) Standards for Medical Services: Strengthen requirements for the authenticity and accuracy of rehabilitation medical records, as well as for consistency between diagnosis and treatment; standardize the reporting of medical insurance data and the procedures for fee settlement; clearly define the usage guidelines for drugs (consumables) and medical service items with high out-of-pocket cost ratios, mandating that patients’ right to informed consent be fully respected prior to their use.

(3) Violation‑based penalty mechanism: Establish a clear tiered penalty system based on the severity of the violation; strictly curb serious violations; resolutely prevent practices such as fragmented hospitalization, bed‑hanging hospitalization, and improper billing substitutions; and strengthen intelligent monitoring, data screening, and retrospective accountability.
The director of the Medical Insurance Office emphasized that the agreement underscores the principle of equal rights and responsibilities, with clear rewards and penalties. The entire hospital must take the agreement as its guiding framework, striking a balance between enhancing service quality and adhering strictly to compliance standards, thereby effectively safeguarding patients’ rights and the integrity of the medical insurance fund.

2. The Medical Insurance Office also conducted training on the “Administrative Measures for Physician Point-Based Management” and analyzed the aggregated data on violations detected by the hospital’s intelligent monitoring system for 2024. In light of the various challenges currently facing the hospital, it proposed corresponding solutions, with particular emphasis on providing standardized responses to common issues encountered in the implementation of VRG-based reimbursement for rehabilitation services.

III. Work Deployment: Pooling Efforts to Build a Comprehensive Service Loop

While conducting training on medical insurance policies for the first batch of medical insurance liaisons, the hospital also set forth clear requirements regarding their duties:

Precise transmission: Promptly communicate updates to medical insurance policies to ensure that all members of the department are fully informed.

Feedback: Establish a regular communication mechanism to promptly address challenging clinical cases.

Quality Control Supervisor: Conduct regular self-assessments of the department’s medical insurance services and collaborate with the Medical Insurance Office to streamline clinical service workflows.

IV. Conclusion

With the goals of “implementing policies, enhancing capabilities, and improving service efficiency,” this conference injects new momentum into the hospital’s medical insurance management. The hospital will leverage the medical insurance liaison system as a key mechanism to further strengthen collaboration between departments and administrative units, fortify safeguards for patients’ medical insurance rights, and propel the hospital’s high-quality development to a new level.