智能审核在医院医保管理中的实践与思考——以苏州某三甲医院为例  

Practice and thinking intelligent audit in hospital's medical insurance management——Take a top three hospital in Suzhou as an example

作　　者：张思源 张华珍[1] ZHANG Si - yuan;ZHANG Hua - zhen(Affiliated Second Hospital o f Suzhou University, Suzhou Jiangsu 215004, China)

机构地区：[1]苏州大学附属第二医院,江苏苏州215004

出　　处：《卫生软科学》2018年第4期52-54,共3页Soft Science of Health

摘　　要：智能审核作为医保基金监管的信息化手段,其结果一定程度上反映了医院医保管理中存在的问题。苏州某三甲医院2016-2017年6月收到初审条目707条,通过医院申诉反馈,复审确认扣款条目64条,问题主要集中在护理费、检查检验费重复收取和错开性别用药3个方面。在存疑条目中,最常见的原因是3天出入院和住院费用异常。违规原因主要包括计费流程、计费人员及计算机系统3个方面。对医保和收费管理提出加强信息系统建设、加强政策学习及培训等建议。Intelligent audit system is as an informationization means of medical insurance fund supervision, the result reflects the problems exist-ing in hospital management at a certain extent A top three hospital in Suzhou received 707 first reading entries from 2016 to Jun. 2017. Through appealing and feedback of hospital, reviewed and confirmed 64 charge entries. The problems were concentrated in nursing and chec-king fee repetition charge, and gave wrong prescription. In questionable items, cause of the most common was that three days admission and discharge, and hospitalization expense exception. Irregularity cases include charging process, charging staffs and computer system. It puts for-ward some improvement measures such as strengthen informationization system construction, policy studying and training to medical insurance and charging management

关 键 词：智能审核 医保管理 信息化 

分 类 号：R197.1[医药卫生—卫生事业管理] F840.684[医药卫生—公共卫生与预防医学]