院内医保合规系统在“除外内容”收费管理中的应用与效果分析  

Application and Effect Analysis of In-hospital Medical Insurance Compliance System in Charge Management of"Excluded Content"

作　　者：翁燕榕[1] 李秋艳[1] WENG Yan-rong;LI Qiu-yan(Fujian Provincial Hospital)

机构地区：[1]福建省立医院

出　　处：《医院管理论坛》2023年第1期82-85,共4页Hospital Management Forum

摘　　要：目的 分析院内医保合规自查系统对“除外内容”收费的合规性和合理性审核及成效。方法 对比2021年1—6月和2022年1—6月两个时间段,系统运行前、后的“除外内容”的违规收费记录。结果 系统运行之前,“除外内容”的违规例数高达12707例,涉及金额545766元;系统运行之后“除外内容”的违规例数下降至1462例,下降幅度达88.49%,涉及金额减少至98228元,减少幅度达82.00%。“除外内容”的违规项目构成比也发生了变化。结论 院内医保合规自查系统能够有效降低“除外内容”收费的违规例数和违规金额,成效显著。Objective To analyze the compliance and rationality audit and effect of"excluded content"charges by in-hospital medical insurance compliance self-examination system.Methods The illegal charging records of"excluded content"before and after the system operation were compared between January-June 2021 and January-June 2022.Results Before the operation of the system,the number of illegal cases of"excluded content"was as high as 12,707,involving an amount of 545,766 yuan;After the operation of the system,the number of illegal cases of"excluded content"dropped to 1,462,with a decrease of 88.49%,and the amount involved decreased to 98,228 yuan,with a decrease of 82.00%.The proportion of illegal items in"excluded content"has also changed.Conclusion The self-examination system of in-hospital medical insurance compliance can effectively reduce the number and amount of violations of"excluded content"charges,and the effect is remarkable.

关 键 词：医保 合规自查系统 除外内容 违规 

分 类 号：R197.3[医药卫生—卫生事业管理]