医院2011-2013年医疗保险门诊拒付原因分析与对策  

Analysis for protest reasons of outpatient medical insurance from 2011 to 2013

作　　者：郝鑫菊 罗艳[1] 刘京伟[1] 王晓虹[1] 裴丽[1] 

机构地区：[1]解放军总医院第一附属医院药剂药理科,北京100048

出　　处：《中国医药》2015年第4期577-579,共3页China Medicine

摘　　要：目的 分析医院2011-2013年医疗保险 门诊拒付的原因并制定相应对策.方法 收集解放军总医院第一附属医院2011年1月至2013年12月的医疗保险门诊拒付材料,对3个年度的各月份医疗保险拒付情况、医疗保险拒付原因、各科室医疗保险拒付情况以及经常被拒付药品的情况进行回顾性分析.结果 2011年拒付人次和金额最多,且在4月和5月达到高峰,而2012年和2013年拒付次数和金额明显减少,各个月份趋于平缓;超剂量用药和超说明书范围用药分别为各年度医疗保险拒付的2个主要原因;科室拒付中,2011-2013年外科、内科的拒付次数均排前2位;各年度的拒付药品种类不尽相同,2011年排在第1位的是阿司匹林肠溶片,而2012年和2013年居首位的均为复方甘草酸苷胶囊.结论 医疗保险拒付仍是难题,减少医疗保险拒付需要有效的管理对策.Objective To analyze the reasons of protest of outpatient medical insurance from 2011 to 2013. Methods Materials of outpatient medical insurance protest from 2011 to 2013 were collected. The situation, the reasons, the departments and the mainly medicines of protest in each month were analyzed retrospectively. Results In 2011, the frequency of protest and the amount of money were the most, especially in April and May; in 2012 and 2013, the frequency of protest and the amount of money decreased significantly. The over-dosage and off label indications medication were two main reasons of protest of outpatient medical insurance ; protest frequency in department of surgery and internal medicine were the top two in each year; the medication types varied in each year. Aspirin Enteric-coated Tablets as the numberl in 2011, and Compound Glycyrrhizin Capsules was thennmberl in 2012 and 2013. Conclusion The protest needs an effective management strategy.

关 键 词：医保门诊拒付 拒付原因 管理对策 

分 类 号：R197.1[医药卫生—卫生事业管理]