医疗机构医保智能审核系统的设计与应用  

Design and application of medical institutions′intelligent medical insurance audit system

作　　者：刘佳玉 王欣 孙晶晶[1] 牛宇翔 范玮玮 魏俊丽[1] Liu Jiayu;Wang Xin;Sun Jingjing;Niu Yuxiang;Fan Weiwei;Wei Junli(Department of Medical Insuranc,Beijing Friendship Hospital,Capital Medical University,Beijing 100050,Chi;Information Center,Beijing Friendship Hospital,Capital Medical University,Beijing 100050,China;Price Office,Beijing Friendship Hospital,Capital Medical University,Beijing 100050,China)

机构地区：[1]首都医科大学附属北京友谊医院医疗保险办公室,北京100050 [2]首都医科大学附属北京友谊医院信息中心,北京100050 [3]首都医科大学附属北京友谊医院物价办公室,北京100050

出　　处：《中华医院管理杂志》2022年第2期97-100,共4页Chinese Journal of Hospital Administration

基　　金：北京友谊医院科研启动基金资助项目(yyqdktgl2021-11)。

摘　　要：近年来我国医保覆盖率显著提高,医保政策不断推陈出新,传统的人工审核方式已无法满足医疗机构对医保基金高效监管的需求。针对这一情况,北京市某三级甲等医院面向重点监管的药品和诊疗项目,通过构建智能化审核规则、设计审核触发点和违规医嘱拦截等级、设立系统运行前准备制度和持续改善机制,成功建立了医保智能审核系统,实现了对医保基金违规使用行为的事前审核、事中控制。2021年3月,医院正式启用该系统,同年4—9月医院门诊医保拒付金额和数量分别为10587元和72笔,较2020年同期下降了79.21%和77.50%,有效提升了医保基金监管的质量和效率。In recent years,the medical insurance coverage of China has been increased significantly,and the medical insurance policies have been launched continuously,so the traditional manual audit method is unable to support medical institutions to effectively supervise the medical insurance fund.In view of this situation,a tertiary hospital in Beijing had successfully built an intelligent medical insurance audit system for drugs,diagnosis and treatment projects under key supervision,realized the prior audit and in-process control of the illegal use of medical insurance funds,through the establishment of intelligent audit rules,the design of audit trigger points and the interception level of illegal medical orders,and the establishment of a pre-operational preparation system and continuous improvement mechanism.In March 2021,the hospital officially launched the system.After the application of the system,the amount and quantity of outpatient medical insurance refusal from April to September 2021 were 10587 yuan and 72 respectively,which decreased by 79.21%and 77.50%compared with the same period in 2020.This system effectively improved the quality and efficiency of medical insurance fund supervision.

关 键 词：医院 公立 医保基金 智能审核 系统 基金监管 

分 类 号：R197.32[医药卫生—卫生事业管理]