某三甲医院门诊药品医保拒付的现状分析  

Analysis of current status of medical insurance payment refusal of outpatient prescription in a tertiary hospital

作　　者：于依水 刘爽 程吟楚 蔡峥 YU Yi-shui;LIU Shuang;CHENG Yin-chu;CAI Zheng(Department of Pharmacy,Peking University Third Hospital,Beijing 100191,China)

机构地区：[1]北京大学第三医院药剂科,北京100191

出　　处：《临床药物治疗杂志》2022年第8期39-43,共5页Clinical Medication Journal

摘　　要：目的分析某三甲医院门诊药品医保拒付现状,明确拒付原因,提出改进措施,提高医保基金使用效率。方法采用描述性分析方法,回顾2019年1—9月某三甲医院门诊患者医保拒付药品费用情况,分析拒付原因及类别,评价拒付结果的合理性。结果门诊被拒付处方中,频次最高的原因为累计开药量超量(占比72.60%),金额最高的原因为超医保目录限制(占比62.81%)。产生医保拒付的原因多种,包括医保政策学习理解不到位、诊断书写不规范、医院药品目录与指南或共识不一致、审核处方不全面、信息系统未能有效拦截、拒付判定不合理等。结论提高医保基金使用效率需要医疗机构加强监管,将医保政策解读传达落实到位,医保规则需与时俱进、动态管理,药品说明书需及时修订,同时利用信息系统将不合理处方拦截。Objective To analyze the status and reasons for medical insurance payment refusal in outpatient department of a tertiary hospital,then propose reasonable suggestions to improve the efficiency of the use of medical insurance funds.Methods Data of medical insurance payment refusal of outpatient prescription of a tertiary hospital from January 1 to September 30,2019,were collected,and the reasons and categories of refusal were analyzed with a descriptive statistical method.Results Among the rejected prescriptions,the most frequent reason was excessive prescribed amount(accounting for72.60%),and the reason for the highest amount of money was beyond the limit of medical insurance directory(accounting for62.81%).The main reasons for insurance refusal included misunderstanding of medical insurance policy,non-standard diagnosis,inconsistency between hospital drug directory and guidelines or consensus,incomplete prescription review,failure of information system to intercept effectively and unreasonable judgment of non-payment.Conclusion To improve the efficiency of the use of medical insurance funds,medical institutions need to strengthen supervision.The interpretation of medical insurance policies should be put into place.Medical insurance rules need to keep pace with the times and be managed dynamically.Drug instructions need to be revised in time.And information systems should be utilized to intercept irrational prescriptions.

关 键 词：门诊药品 医保拒付 合理用药 超医保目录限制 

分 类 号：R95[医药卫生—药学]