公立医院医保管理智能审核系统应用  

Application of an intelligent audit system for medical insurance management at public hospitals

作　　者：孔德明[1] 曾丽芳 易懿[1] 王毅[1] Kong Deming, Zeng Lifang, Yi Yi, Wang Yi.(The Ninth Peoplet＇s Hospital of Chongqing, Chongqing 400700, China)

机构地区：[1]重庆市第九人民医院,400700

出　　处：《中华医院管理杂志》2018年第11期936-939,共4页Chinese Journal of Hospital Administration

基　　金：重庆市北碚区科学技术委员会科技计划项目（2017-10）

摘　　要：通过分析医保政策、医保审核业务和医改提出的智能监控需求，建立了智能审批数据库。联合医院管理信息系统、检验信息系统、电子病历系统等，进行系统流程再造，成功开发并启用了医保智能审核信息系统，实现了外伤患者医保资格自动审核、使用血液制品项目自动审核、高额费用自动审核、10日内重复住院自动审核、出院诊断自动更新匹配、药品（诊疗）项目限制（超量）预警等核心业务功能，满足了医院内部医保审核数据管理质量与效率的实际需求，为规范医生诊疗行为和规避医院风险提供了基础平台和数据支撑。By analyzing the medical insurance policy, the medical insurance audit business and the intelligent monitoring requirements put forward by the medical reform, the intelligent examination and approval database was established, and the system process reengineering was carried out in conjunction with HIS, LIS and electronic medical record systems. The intelligent medical insurance audit information system was successfully developed and implemented, which realized automatic review of the medical qualifications of trauma patients, automatic audit of blood product items, automatic verification of high-cost fees, automatic review of repeated hospitalizations within 10 days, and automatic update of discharge diagnosis, as well as drug（diagnosis/treatment） project limits （excessive）early warning and other core business functions. The system meets the actual needs of the quality and efficiency of data management in medical insurance audit, providing basic platform and data support for standardizing doctors＇ diagnosis and treatment behavior and avoiding hospital risks.

关 键 词：医院 公立 医院信息系统 医疗保险 智能审核 设计 

分 类 号：R197.32[医药卫生—卫生事业管理]