公立医院医保全场景智能管理探索  

Practice and exploration of whole scene intelligent management of medical insurance in public hospitals

作　　者：李丹 欧凡[2] 伍睿 杨小红 Li Dan;Ou Fan;Wu Rui;Yang Xiaohong(Department of Information Management,Guangdong Provincial People′s Hospital,Gudong Academy of Medical Sciences,Guangzhou 510080,China;Medical Insurance Office,Guangdong Provincial People′s Hospital,Gudong Academy of Medical Sciences,Guangzhou 510080,China)

机构地区：[1]广东省人民医院(广东省医学科学院)信息管理处,广州510080 [2]广东省人民医院医(广东省医学科学院)疗保险事务处,广州510080

出　　处：《中华医院管理杂志》2022年第2期92-96,共5页Chinese Journal of Hospital Administration

摘　　要：随着我国医保支付方式的改革和医保政策的推进,医保管理已经成为公立医院运营管理的核心板块。根据公立医院医保管理的业务场景,医保智能管理可以分为基于规则的自动化医保智能管理引擎、基于对话式用户界面的数字医保管理助力和基于深度学习的医院医保管理大脑3个层次。2020年8月,某三级甲等医院在医院智慧管理标准要求下,突破传统医保管理模式,启动了数字赋能的医保全场景智能管理实践,包括医保智能业务审核、医保智能对账、医保智能费用及成本管控和医保智能管理驾驶舱,实现了医保管理的智能化和规范化,提升了医院整体运营效能。With the reform of medical insurance payment mode and the promotion of medical insurance policy,medical insurance management has become the core of public hospital operation and management.According to the business scenario of medical insurance management in public hospitals,medical insurance intelligent management can be divided into three levels:automatic medical insurance intelligent management engine based on rules,digital medical insurance management assistance based on dialogue user interface and hospital medical insurance management brain based on deep learning.In August 2020,under the requirements of hospital intelligent management standards,a tertiary hospital broke through the traditional medical insurance management mode to launch the practice of digital enabled panoramic scene intelligent management of medical insurance,which included medical insurance intelligent business audit,medical insurance intelligent reconciliation,medical insurance intelligent cost control and medical insurance intelligent management cockpit.These measures had realized the intellectualization and standardization of medical insurance management and improved the overall operation efficiency of the hospital.

关 键 词：公立医院 智慧管理 医保智能管理 全景场景 

分 类 号：TP399-C8[自动化与计算机技术—计算机应用技术] R197.32[自动化与计算机技术—计算机科学与技术]