医疗保险自动划价系统的设计应用  

Design and Application of Automatic Calculating System of Medical Insurance

作　　者：潘大钊[1] 张鑫[1] 任慧朋 

机构地区：[1]解放军98医院信息科,浙江湖州313000

出　　处：《华南国防医学杂志》2018年第1期51-54,共4页Military Medical Journal of South China

基　　金：南京军区医学科技创新项目(MS010)

摘　　要：目的医疗保险智能审核系统的上线对医院医保病人的费用划价与审核提出了更高的要求,为适应新需求,对原有后台划价进行重新编程。方法在实现原后台划价系统原有功能的基础上,修改算法,新增控制规则,使划价结果符合医保智能审核平台相关的规则要求。结果经测试使用,修改后该系统有效地消除了日期型计价数量的小数点以及单日计价量超次数等问题。结论与原系统比较,升级后满足了部分医疗保险智能审核要求,提高了医院医保办审核效率,减少了医保办对违规数据的人工反馈工作量。Objective To reprogram the original background automatic calculating system for adapting new requirement and higher demand of automatic calculating and medical expense audit in medical insurance patients when medical insurance expense audit system was on-line.Methods Based on the initial functions of the original back-end calculating system,the algorithm was modified and new control rules were added,so that the calculating results met the requirements of the related rules of the medical insurance audit platform.Results After testing,decimal point of date-based pricing,frequency of single-day pricing and other problems were effectively eliminated by modified system.Conclusion Comparing with the original system,upgraded medical insurance smart audit satisfies part requirements,improvs the audit efficiency of hospital medical insurance administration,and reduces the manual feedback workload of medical insurance office on irregular data.

关 键 词：医疗保险 智能监管 自动划价 医保费用审核 POWERBUILDER编程 医保政策 

分 类 号：R197[医药卫生—卫生事业管理]