On September 19, the Qinghai Provincial Medical Insurance Bureau made an important announcement: starting from October 1, 2024, 127 outpatient surgeries across 71 disease categories will be incorporated into the medical insurance reimbursement system.
This initiative is designed to improve the efficiency of medical insurance fund usage while alleviating the financial burden on patients by reforming payment methods for outpatient surgeries. Specifically, these surgeries will be classified as outpatient if they can be completed within 48 hours, without the need for extended hospital stays.
In line with current practices within medical institutions, the Qinghai government has identified these 127 outpatient procedures as qualifying for insurance reimbursement. Hospitals that are at least of secondary level and meet the necessary standards for conducting outpatient surgeries will manage the insurance payments for these services.
For residents covered by urban employee or rural resident medical insurance in Qinghai, costs related to outpatient surgeries will be eligible for basic medical insurance coverage, contingent upon a thorough pre-surgery assessment at the medical facility. Notably, there will be no minimum payment threshold. Reimbursements will follow the Diagnosis Related Group (DRG) methods or the Disease Classification Point (DIP) standards. Should patients experience complications that necessitate further care post-surgery, they will have the option to request a change to regular inpatient status.
Moreover, expenses incurred from pre-operative outpatient examinations and tests conducted at the same facility, directly linked to the upcoming outpatient surgery, will also be included in the reimbursement plan. Medical institutions are encouraged to streamline outpatient surgeries through dedicated “green channels,” ensuring timely completion of pre-operative assessments and tests.
Furthermore, any medical facility wishing to introduce new outpatient surgeries must comply with established clinical pathways or treatment protocols that guarantee the use of appropriate technology, quality control, safety measures, and cost-effectiveness. These institutions will submit applications to local medical insurance authorities for the addition of new outpatient surgery categories, which will then be reviewed and approved by the Provincial Medical Insurance Bureau before being integrated into the reimbursement framework.
