新时期优化医保智能审核系统的建议与思考  

Thoughts on the Medical Insurance Intelligent Audit System in the New Era

作　　者：李天俊[1] 滕世伟 杨华[2] 冯海欢[2] 孙麟[2] 

机构地区：[1]四川大学华西医院医保办公室流程与项目组,成都610044 [2]四川大学华西医院,成都610044

出　　处：《中国医疗保险》2022年第6期70-73,共4页China Health Insurance

摘　　要：医保智能审核系统提高了医保经办机构的审核效率,提升了医院上传的数据质量,也在一定程度上规范了医疗机构的诊疗、收费行为,但仍存在侦测医疗合理性、真实性能力有待提升,审核规则设置缺少依据,规则内涵不明确等问题。本文分析了智能审核系统在医保基金监管中的成效以及问题,结合医保政策以及医保基金监管形势提出意见建议,以期为智能审核系统更好地应用于基金监管提供参考。The medical insurance intelligent audit system improves the audit efficiency of medical insurance agencies, promotes the quality of data uploaded by hospitals, and standardizes the diagnosis, treatment and charging behavior of medical institutions. However, the medical insurance intelligent audit system still has some problems. The ability to detect the rationality and authenticity of medical treatment needs to be improved, the audit rule setting is lack of basis, and the rule connotation is ambiguous. This paper analyzes the effect and problmes of medical insurance intelligent audit system, puts forward suggestions on the application of intelligent medical insurance fund in the review of medical insurance policy, and provides better reference for the application.

关 键 词：医保智能审核 医保基金监管 监控 

分 类 号：F840.684[经济管理—保险] C913.7[社会学]