某院异地医保结算现状分析  

Analysis of the Status Quo of Settlement of Remote Medical Insurance in a Hospital

作　　者：杜会征 李慧[1] 焦卫平[2] DU Huizheng;LI Hui;JIAO Weiping(Xuanwu Hospital,Capital Medical University,Beijing,100053,China)

机构地区：[1]首都医科大学宣武医院,北京100053 [2]首都医科大学宣武医院医疗保险管理办公室,北京100053

出　　处：《中国卫生质量管理》2021年第10期51-54,共4页Chinese Health Quality Management

摘　　要：目的调查北京某医院异地就医结算管理现状,分析存在问题并提出建议,为完善异地医保管理提供参考。方法采用回顾性研究方法,调取2017年-2019年该院异地医保结算患者原始数据,进行描述性统计分析。结果异地医保结算患者分布以河北、山东、山西为主;患者平均年龄为54岁;出院结算科室涉及神经外科、神经内科、普通外科等23个临床科室;异地医保结算时间从2017年5.5 d缩短至2019年1.6 d,医保基金拒付金额呈下降趋势。结论建议政府强化分级诊疗体系建设,引导异地患者合理有序就医;医院应重视审核部门压力与结算效率之间的平衡;参保人应主动了解异地就医结算政策,自觉遵守相关规定等。Objective To investigate the current situation of settlement management of remote medical insurance in a hospital in Beijing,analyze the existing problems and put forward some suggestions to provide reference for improving remote medical insurance management.Methods Retrospective study method was used to collect the original data of successful settlement of remote medical insurance patients in the hospital from 2017 to 2019 for descriptive statistical analysis.Results Hebei,Shandong and Shanxi were the main areas of settlement patients of remote medical insurance.The mean age of patients was 54 years.The discharge settlement department involves 23 clinical departments such as neurosurgery,neurology,general surgery,etc.The settlement time of remote medical insurance was shortened from 5.5 days in 2017 to 1.6 days in 2019,and the amount of non-payment of medical insurance fund showed a decreasing trend.Conclusion It was suggested that the government should strengthen the construction of the hierarchical diagnosis and treatment system,and guide patients to seek medical treatment in a reasonable and orderly manner.The hospital should attach importance to the balance between the pressure of audit department and settlement efficiency.The insured shall take the initiative to understand the policy of settlement of off-site medical treatment and conscientiously abide by relevant regulations.

关 键 词：异地就医 医疗保险 直接结算 医疗服务 

分 类 号：R197.322[医药卫生—卫生事业管理]