门诊医保实时结算拒付原因分析及对策  

Reason Analysis on The Payment Refusal in The Real Time Settlement of Medical Insurance in Outpatient Clinics and Relevant Countermeasures

作　　者：徐杰[1] 牛继平[1] 谭玉琴[1] 张新庆[1] 

机构地区：[1]北京市垂杨柳医院,北京市100022

出　　处：《中国病案》2013年第10期45-47,共3页Chinese Medical Record

摘　　要：目的减少医保拒付,促进合理诊疗。方法选取我院2011-2012年医保参保患者的门诊拒付数据,对造成拒付情况的原因、所在科室进行统计,对2011年和2012年的拒付率进行卡方检验。结果我院2012年前9个月(1月1日至9月30日)门诊医保实时结算拒付率与2011年9个月的拒付率比较,经卡方检验,差异有统计学意义(P<0.001)。结论通过加强医保政策的宣教、针对个别医师进行单独约谈、完善信息系统的建设、增加门诊医师工作站的提示功能、定期抽查与监督门诊处方等措施,可以减少医保拒付的发生率。Objective To reduce the occurrence of payment refusal in real time settlement of medical insurance and promote rea- sonable diagnosis and treatment. Methods The reasons of the payment refusal in real time settlement of medical insurance in our hos- pital from 2011 to 2012 were selected, and made statistics on related departments as well as comparative analysis. Then conducted 2 Test on the refusal rate. Results The payment refusal rate in real-time settlement of medical insurance in our hospital was decreased significantly in nine months of 2012 compared .with 2011 according to Z2 Test. Conclusions Through measures such as strengthen the propganda and education of medical insurance rules, single turning around aimed at individual doctor, complete the establishment of information system, increase the indication function of doctor working station, inspection timely and supervise outpatient prescrip- tion, can we expect to decrease the occurrence of payment refusal of medical insurance.

关 键 词：医疗保险 实时结算 拒付 

分 类 号：F842.6[经济管理—保险]