某三甲医院医保基金拒付原因分析与对策  

Causes and countermeasures on medical insurance fund refusing to pay in a top tertiary hospital

作　　者：王方[1] 方鹏骞[2] 徐慧娟 

机构地区：[1]中国人民解放军武汉总医院,湖北省武汉市武珞路627号430070 [2]华中科技大学同济医学院

出　　处：《中国医院》2017年第10期63-65,共3页Chinese Hospitals

基　　金：国家自然科学基金重点项目(基于利益均衡和制度整合的我国全民医疗保险体系构建和制度安排研究)(71333005)

摘　　要：目的:分析医保拒付原因,并提出合理化建议,为定点医院加强管理提供参考依据。方法:分析武汉市某三甲医院2015年医保拒付情况,进行分类汇总,采取前后对照研究,分析干预前后医保拒付金额的变化。结果:干预前,医保拒付金额211185元,拒付率1.69%。通过一系列干预措施,医保拒付得到有效控制,并逐步下降,拒付金额最低下降至20637元,拒付率最低下降至0.16%,下降率为90.23%。结论:医保拒付管理是一项连续性、不间断的工作,贯彻落实医保政策、严格病案书写制度可以逐步稳定地规范医院管理,降低医保拒付,模拟智能审核程序则是一种有效的管理工具,是有效降低医保拒付的直接手段。Objectives：To analyze the reasons of medical insurance funds refuse to pay and put forward reasonable suggestions and to provide reference for strengthening the management of medical insurance contracted hospital. Methods：Materials of health insurance withhold payment from 2015 were collected in a top tertiary hospital. Dates were classified and changes before and after intervention were comparatively analyzed. Results：Before the intervention, the amount of health insurance withhold payment is $211185, the rejection rate is 1.69%. Through a series of measures, the amount of withhold payment have been gradually decline. The minimum amount of health insurance withhold payment is $20637 and the lowest rejection rate is 0.16%, decreased is 90.23%. Conclusions： The management of health insurance withhold payment is a continuous work. Strict implementing medical insurance policy and medical record writing can gradually standardize hospital management and decrease the amount of withhold payment. Simulative computer audit program is a kind of effective tool to direct reduce the health insurance withhold payment.

关 键 词：医保拒付 医院管理 智能审核 医疗保险 

分 类 号：R197.1[医药卫生—卫生事业管理]