Notice from the General Office of the National Healthcare Security Administration on Further Strengthening Intelligent Oversight of Excessive and Inappropriate Medication

To: Healthcare Security Bureaus of All Provinces, Autonomous Regions, Municipalities Directly Under the Central Government, and the Xinjiang Production and Construction Corps,

In order to implement the requirements of the nationwide campaign to address prominent problems in healthcare fund management and strengthen source governance, this notice is issued regarding the enhancement of intelligent oversight concerning excessive and inappropriate medication.

I. Objectives and Tasks

Further deepen pilot reforms in intelligent oversight. Relying on the national unified healthcare information platform, establish and improve an intelligent monitoring, screening, and early warning mechanism for issues related to excessive and inappropriate medication. Promote the shift of oversight to earlier stages and build a more rigorous and effective intelligent oversight system for healthcare funds, firmly safeguarding the security baseline of these funds. Advance related work in three phases:

(1) Launch Pilots and Explore Approaches. By the end of December 2025, pilot regions for national intelligent oversight reform must include at least 50 high-risk categories of near-patient (commonly prescribed) healthcare insurance-covered drugs within the scope of intelligent oversight.

(2) Full Rollout with Progressive Coverage. By the end of June 2026, healthcare security bureaus in all provinces, autonomous regions, municipalities directly under the central government, and the Xinjiang Production and Construction Corps must include at least 100 high-risk categories of near-patient healthcare insurance-covered drugs within the scope of intelligent oversight.

(3) Comprehensive Application and Mechanism Formation. By the end of December 2026, healthcare security departments at all levels nationwide must achieve comprehensive intelligent oversight coverage for high-risk categories of near-patient healthcare insurance-covered drugs. Establish nationally unified and standardized intelligent oversight rules and perfect the working mechanism that effectively links data screening, reminder/warning, investigation, and punishment.

II. Focus Areas

(1) Concentrate on Three Key Aspects.

Focus on three key types of healthcare insurance-covered drugs: 1) Key drugs frequently involved in cases of illegal or irregular use of healthcare funds; 2) Key drugs with high amounts paid by the pooled fund, ranking at the top, especially those showing abnormal growth in fund expenditure; 3) Key drugs with high demand for resale and significant profit margins. The National Healthcare Security Administration will compile a list of high-risk categories of near-patient healthcare insurance-covered drugs for reference by local healthcare security departments.

Focus on three key types of abnormal behaviors: 1) Purchasing excessive quantities of medication without justifiable reason, significantly exceeding the reasonable medication range within a certain period; 2) Obtaining duplicate prescriptions from multiple institutions within a short time frame without significant change in medical condition or medication needs; 3) Other abnormal prescription behaviors within a short timeframe, such as frequent purchases or obtaining medication under someone else's name.

Focus on three key types of institutions and individuals: 1) Insured individuals suspected of exploiting insurance benefits to obtain excessive prescriptions for resale; 2) Designated healthcare institutions and their departments where excessive prescribing is concentrated; 3) Medical personnel suspected of assisting or inducing others to violate regulations by obtaining excessive, duplicate, or fraudulent prescriptions.

(2) Carry Out Three Key Tasks.

First, Strengthen data screening and analysis. Construct various big data oversight models, effectively utilize drug traceability code information, identify suspicious leads through screening and analysis, determine key drug lists prone to resale and diversion, pinpoint abnormal prescription behaviors like excessive, duplicate, or frequent prescriptions, and create precise "profiles" of implicated designated healthcare institutions and insured individuals. Focus monitoring on insured individuals identified via big data screening as suspected of exploiting benefits for excessive prescriptions or resale, as well as implicated designated healthcare institutions, their departments, physicians, and pharmacists.

Second, Enhance precise reminders and warnings. Relying on the healthcare information platform, establish reminder and warning functional modules. Push analyzed abnormal prescription behaviors to designated healthcare institutions to effectively apply data screening results at the pre-event reminder stage. Improve the precision of warnings, avoiding broad, undifferentiated alerts, thereby strengthening the shift of oversight upstream and source control. In oversight and audit work, prioritize the review of insurance settlement documents involving key monitoring targets, increase manual sampling, conduct on-site inspections for clearer leads, and perform special unannounced inspections when necessary.

Third, Intensify investigation, punishment, and exposure. Adhere to the principles of balancing leniency with severity, differentiated treatment, and categorized handling. Encourage designated healthcare institutions and insured individuals to conduct self-inspection and correction. Deal leniently and appropriately with institutions that proactively identify issues, return funds, and promptly improve internal management systems, as well as insured individuals who voluntarily reimburse fund losses, in accordance with laws and regulations. Resolutely investigate, punish, and expose those with egregious nature, serious circumstances, repeated violations, or refusal to correct. For personnel at designated healthcare institutions, strictly apply scoring according to relevant regulations on insurance payment eligibility management, suspending or terminating such eligibility. For insured individuals violating laws/regulations, apply restraining measures such as interviews, legal education, signed commitments, and strengthened fund usage audit management.

III. Work Requirements

(1) Respect medical science and clinical reality, safeguarding reasonable medication needs. Fully respect actual clinical diagnosis and treatment practices. Strictly distinguish between the public's legitimate need for medication and behaviors like exploiting insurance benefits for excessive prescriptions or reselling medication. Maintain appropriate rule flexibility to ensure the secure operation of healthcare funds. Promptly adjust and optimize rules or knowledge points found to impact insured individuals' reasonable medication needs. Appropriately adjust oversight based on objective circumstances for legitimate needs arising from actual treatment requirements (e.g., necessary excessive prescriptions due to therapy), or reasonable medication stockpiling for travel, holidays, etc.

Annex: List of 50 High-Risk Healthcare Insurance-Covered Drugs Prone to Resale and Diversion for Phase I Monitoring (Omitted)

General Office of the National Healthcare Security Administration

October 22, 2025

(Actively Published)