The National Healthcare Security Administration (NHSA) has just issued the Circular on Doing a Good Job in the Supervision of Medical Insurance Fund in 2026, announcing nine key work priorities.

01 Continue the Special Rectification of Prominent Issues in Medical Insurance Fund Management

Building on the achievements of the 2025 special rectification of prominent issues in medical insurance fund management, the NHSA will work with relevant departments to continue the special rectification and unswervingly "reduce existing irregularities and curb new ones" in regard to insurance fraud and deception. Healthcare security departments at all levels shall further raise their ideological awareness, resolutely shoulder the political responsibility of safeguarding the security of medical insurance funds, take the special rectification as a top priority, ensure the primary person in charge bears overall responsibility, and adopt multiple measures to intensify rectification efforts and push the special rectification work to go deeper and achieve solid results. We must uphold integrity and innovation, consolidate and deepen progress, thoroughly summarize effective experiences and achievements of the special rectification, and institutionalize a batch of mature practices; adhere to a problem-oriented approach and focus on key points, closely track prominent issues and new situations and problems strongly reflected by the public, and intensify crackdown efforts; adopt a holistic approach to address both symptoms and root causes, strengthen source governance around in-depth problems, improve long-term mechanisms, and realize the goal of promoting rectification and governance through inspections.

02 Fully Promote the Expansion and Quality Improvement of Unannounced Inspections

We will continue to intensify unannounced inspections, coordinate national unannounced inspections, provincial unannounced inspections and municipal cross-inspections, and advance annual unannounced inspections, special unannounced inspections and "targeted" unannounced inspections in a coordinated manner, so as to achieve full coverage of unannounced inspections across all provinces in China, covering all entities such as designated medical and pharmaceutical institutions, handling agencies, insured individuals and insured units, and all insurance types including basic medical insurance, maternity insurance, critical illness insurance and long-term care insurance. Annual unannounced inspections will focus on co-ordination regions with high operational risks of medical insurance funds, abnormally high hospitalization rates, abnormal medical insurance payment rates and inadequate rectification of problems found in previous unannounced inspections; designated medical and pharmaceutical institutions with large fund usage and concentrated clues of problems from reports and big data screening; and key fields such as orthopedics, oncology, laboratory and imaging tests, ophthalmology, stomatology, general surgery and neurology. Special unannounced inspections will focus on prominent illegal and irregular acts of medical insurance fund use that are the focus of social attention and strongly reflected by the public. We will explore the launch of special unannounced inspections on long-term care insurance. "Targeted" unannounced inspections will focus on conducting efficient and concise inspections in response to abnormal clues from big data screening, clue from reports and complaints, and institutions with abnormally high self-payment rates. Healthcare security departments at the provincial level shall strengthen organizational leadership, actively cooperate with national unannounced inspections, carry out in-depth provincial unannounced inspections, and coordinate and guide municipal cross-inspections to ensure the solid and orderly development of unannounced inspection work in 2026.

03 Expand and Deepen the Supervision and Application of Drug Traceability Codes

We will continue to carry out special campaigns to crack down on illegal and irregular acts in the medical insurance field by using drug traceability codes, consolidate the high-pressure posture of cracking down on the resale of medical insurance refunded drugs, and accurately crack down on drug-related illegal and irregular acts such as reselling refunded drugs, substituting medical insurance drugs, fraudulently swiping medical insurance certificates, and overprescribing drugs. We will continue to screen abnormal clues from drug traceability codes and issue them to local authorities for verification and disposal in phases. We will deepen the joint inspection and handling mechanism with public security, drug supervision and other departments, and conduct an all-chain in-depth crackdown on professional prescribers, drug traffickers, pharmaceutical wholesale enterprises, medical and pharmaceutical institutions, online drug sales platforms and other parties suspected of reselling refunded drugs. We will deepen coordination and linkage with drug supervision departments, push the crackdown on the resale of medical insurance refunded drugs to extend to self-paid and non-designated medical and pharmaceutical institutions, form a closed supervision loop, and more comprehensively and in-depth curb the chronic problem of refunded drugs. We will increase the application of information technology, fully expose information on refunded drugs, ensure that drug traffickers receive due punishment, and firmly establish a social consensus and atmosphere that "recycling refunded drugs is illegal and selling them is a crime".

04 Innovate and Explore the Supervision and Application of Cutting-edge Technologies such as Artificial Intelligence and New Scenarios

We will continue to increase the R&D and application of various big data supervision models, focus on typical illegal and irregular acts, drugs and consumables, diagnosis and treatment items, key groups, diseases and insurance types, and constantly enrich and improve the matrix of big data supervision models. We will continue to innovate and expand the practical paths and application scenarios of "artificial intelligence + medical insurance supervision". Based on the construction of "one file per disease", we will explore and develop single-disease and multi-disease supervision models adapted to DRG/DIP payment methods, solve supervision difficulties such as overcoding, split hospitalizations and cost shifting under DRG/DIP payment methods, and promote the transformation of fund supervision from item-based supervision to coordinated item and disease-based supervision; based on the construction of medical insurance imaging cloud platform, we will explore "artificial intelligence + image recognition" to accurately detect illegal and irregular acts such as abnormal use of implantable consumables, fake inspections, repeated inspections and fabricated medical conditions; based on multi-dimensional data collection, we will explore "artificial intelligence + medical record interpretation" to provide clue support for the supervision of over-treatment and fake diagnosis and treatment; based on national medical insurance policies, we will explore the construction of "artificial intelligence + medical insurance rules", through which artificial intelligence automatically generates supervision rules, screens suspicious clues and accurately identifies problems; based on the R&D of new technologies, we will explore the supervision application of diverse technologies such as thermal imaging, millimeter-wave radar and scene capture. We will continue to promote the transformation and application of the achievements of big data anti-fraud supervision pilots, and mature local supervision models will be embedded in the national medical insurance information platform after being verified effective by the NHSA and promoted nationwide. We will carry out in-depth pilot reforms of intelligent supervision, encourage local authorities to boldly explore and take the lead in trials, innovate in the practical exploration of "artificial intelligence + medical insurance supervision", and timely summarize replicable and promotable experiences and practices. The NHSA will strengthen overall coordination, guidance and follow-up evaluation, and provide policy support and experience promotion for local innovative practices.

05 Fully Strengthen Clue Verification and Problem Disposal and Rectification

Healthcare security departments at all levels shall earnestly conduct clue verification, timely feed back investigation and punishment results of report and complaint clues and suspicious clues from big data screening issued by the NHSA within the time limit, and provincial healthcare security departments shall strictly review the fed back verification results. We shall strictly handle the follow-up disposal of illegal and irregular problems, and comprehensively use methods such as agreement management, administrative punishment and payment qualification management to ensure the effect of punishment and education. For institutions involved in insurance fraud and deception, we will resolutely terminate or suspend the medical insurance designated institution agreement, strictly refuse to accept applications for designated status within a time limit in accordance with regulations, and impose score penalties on the payment qualifications of relevant personnel. We will increase the exposure of typical cases and internal notifications to strengthen warning and deterrence. We will deepen the mechanism of "coordination between administrative departments, between administrative law enforcement and criminal justice, and between administrative supervision and disciplinary inspection", and strengthen multi-angle investigations of a single case and joint disciplinary actions. We shall learn lessons from one case to avoid similar ones, promote rectification and governance through inspections, and in view of universal, regional and prominent problems found in inspections, urge comprehensive self-inspections and promote overall governance through forums, interviews and collective education. The NHSA will organize special unannounced inspections in a timely manner, conduct random checks and reviews on report and complaint clues and suspicious clues from big data screening with questionable verification results, and conduct "re-inspections" on those with inadequate disposal and rectification of problems found in unannounced inspections. Those who fail to investigate cases, cover up and condone irregularities, work in a perfunctory manner will be seriously dealt with.

06 Continuously Improve the Whole-process Intelligent Supervision System for Pre-event Reminder, In-event Review and Post-event Supervision

We will coordinate the construction of the "three lines of defense" including pre-event reminders at medical and pharmaceutical institutions, in-event reviews at handling agencies and post-event supervision at administrative departments, forming a synergistic effect of tiered interception of illegal and irregular acts. We will push the supervision forward, strengthen pre-event reminders, eliminate all kinds of illegal and irregular acts in the bud, and continuously reduce the occurrence of illegal and irregular problems. Adhering to a "two-pronged approach", we will accelerate the implementation and application of the pre-event reminder system, and strive to achieve an access rate of over 70% for designated medical and pharmaceutical institutions by the end of 2026. For small and medium-sized medical and pharmaceutical institutions, we encourage them to access the pre-event reminder function module of the provincial medical insurance information platform for free use; for large medical and pharmaceutical institutions with strong technical strength and good information infrastructure, we encourage them to embed the publicly released national "two databases" rules and knowledge points into the hospital HIS system to improve operational efficiency and meet personalized management needs. The NHSA will organize and plan to dynamically release the "two databases" rules through the deployment of intelligent supervision systems, public publishing of books, official website and official WeChat account, continuously empower healthcare security departments at all levels and the majority of designated medical and pharmaceutical institutions, and provide strong support for pre-event reminder work. We will improve the effective connection mechanism of pre-event, in-event and post-event work. We will regularly summarize and collect mature and effective rules and knowledge points formed in pre-event reminders and in-event reviews, and incorporate them into the "two databases" in a timely manner after research and demonstration; actively promote the intelligent supervision pre-event reminder work for overprescribing drugs, and timely push mature and appropriate rules from post-event supervision to pre-event and in-event links, so as to empower pre-event reminders and in-event reviews through post-event supervision.

07 Constantly Improve the Long-term Institutional Mechanism for Supervision

We will accelerate the issuance of the Implementation Rules for the Regulations on the Supervision and Administration of the Use of Medical Insurance Funds, formulate supporting administrative law enforcement discretion benchmarks, and strengthen publicity, training and implementation. We will study and formulate policy measures to further strengthen the supervision and administration of the use of individual accounts of employees' basic medical insurance in designated retail pharmacies and standardize the use of individual account funds. We will study and formulate relevant systems for the supervision of long-term care insurance funds. We will continue to carry out self-inspection and self-correction in designated medical and pharmaceutical institutions, and compact the main responsibility of designated medical and pharmaceutical institutions. We will fully implement the medical insurance payment qualification management system, improve measures such as scoring circumstances, scoring rules and information disclosure, accelerate the national networking of scoring information, and encourage designated medical and pharmaceutical institutions to link personnel scores with performance appraisal, professional title promotion, and selection of advanced individuals and collectives. We will explore the development of a credit management mechanism that attaches equal importance to incentives and constraints. We will carry out pilots of credit management mechanisms for designated medical and pharmaceutical institutions, distinguish different types and levels of institutions, conduct scoring by comprehensively considering illegal and irregular situations, self-inspection and self-correction, internal control, and cooperation with supervision and inspections, and link the scoring results with inspection frequency and performance appraisal.

08 Actively Promote Targeted Publicity, Education and Guidance

We will study and formulate the Guiding Opinions on Further Strengthening the Publicity, Education and Guidance of Medical Insurance Fund Supervision, establish a normalized publicity and education mechanism, guide all entities involved in the use of medical insurance funds to take the initiative to be self-disciplined, self-reflective and self-alert, and fully create a good atmosphere for the rational and standardized use of medical insurance funds. We will adhere to the combination of positive and negative publicity, increase the intensity and frequency of publicity and training, continue to organize the centralized publicity month of medical insurance fund supervision, and improve the society's understanding and grasp of medical insurance laws, regulations and policies through door-to-door policy delivery, special training, centralized publicity and Q&A sessions; select typical negative cases to carry out case-based law popularization and warning education. We will adhere to the distinction between internal and external publicity, and in accordance with the principle of "distinguishing the nature and classifying the disposal", resolutely make public exposure of serious, recalcitrant or widespread problems to strengthen warning and deterrence; for general irregular problems with minor circumstances and emerging tendencies, we will strengthen education and guidance through extensive and frequent window guidance, forums, interviews and internal notifications. We will adhere to targeted publicity and education, and for different entities such as hospitals, pharmacies and insured individuals, different nature such as public and private, different scales such as large, medium and small, and different irregular acts such as insurance fraud and deception, over-treatment and irregular charging, we will classify and produce highly targeted and typical warning education materials, and carry out extensive classified training and education. Through accurate and powerful "alarm ringing", we will promote rectification and governance through case analysis.

09 Strive to Strengthen the Legalization, Standardization, Professionalization and Integrity of Fund Supervision

We will adhere to law-based administration, standardize administrative discretion, improve the law enforcement procedures for fund supervision, and strengthen law enforcement supervision. We will fully promote the application of modules such as fund supervision unannounced inspections, reports and complaints, clue verification and administrative law enforcement on the national medical insurance information platform, strengthen the whole-process management of unannounced inspections, continuously standardize inspection procedures, improve the identification standards for illegal and irregular problems, and unify and standardize unannounced inspection documents and reports. We will earnestly implement the reporting system for major issues, and timely report major issues such as clues of major cases, emerging problems and the disposal of national unannounced inspection results to the NHSA. We will strengthen the professional capacity training of supervision personnel, improve the training system for medical insurance fund supervision, strive to strengthen the cultivation of compound capabilities, and establish an expert database for fund supervision consultation. We will strengthen the discipline and work style construction of the fund supervision team, adhere to the bottom line of integrity and self-discipline, resolutely implement the "Ten Prohibitions" for unannounced inspections, continuously improve the ability of the medical insurance fund supervision system to resist corruption and prevent degeneration, and create a good atmosphere in the whole system that encourages rigorous work, courage to take responsibilities and proactive actions.

Source: National Healthcare Security Administration