北京某医院构建全流程医保基金自监管体系实践探索  

A practical exploration of building a self-regulatory system for a whole-process medical insurance fund in a hospital in Beijing

作　　者：朱静[1] 许丽[1] ZHU Jing;XU Li(Beijing Chao-Yang Hospital Affiliated to Capital Medical University,Beijing,100020,PRC)

机构地区：[1]首都医科大学附属北京朝阳医院,北京市100020

出　　处：《中国医院》2023年第5期97-100,共4页Chinese Hospitals

摘　　要：目的:构建医院全流程医保基金自监管体系,提高医保精细化管理水平。方法:汇总2018-2022年上级管理部门下发的医保基金监管重点项目、各类专项检查项目、日常拒付项目、院内自查项目等医保基金监管重点问题,形成医保管理信息库,运用根本原因分析法、问卷调查、头脑风暴、访谈调查方法,分析问题产生的原因,针对问题原因建立医院医保自监管体系,实施医院医保基金使用PDCA循环自监管。结果:医院从医务人员政策培训、过程监管、业务流程改造、合理引导参保人员4方面开展医院自监管。结论:医院应主动建立院内医保自监管机制,医保基金全流程实施全面管理,提高医保精细化管理水平,保障医保基金安全使用,促进医疗机构高质量发展。Objective:To build a self-regulatory system for the whole process of medical insurance funds in hospitals,and improve the level of refined management of medical insurance.Method:Summarize the key issues of medical insurance fund supervision issued by the superior management department from 2018 to 2022,various special inspection items,daily refusal items,self-inspection items in the hospital and other key medical insurance fund supervision issues,form a medical insurance management information database,and use the root cause Analytical methods,questionnaire surveys,brainstorming,and interview survey methods are used to analyze the causes of problems,establish a hospital medical insurance self-regulation system for the causes of problems,and implement self-regulation of the hospital medical insurance fund using the PDCA cycle.Results:The hospital carried out hospital self-supervision from four aspects:medical staff policy training,process supervision,business process transformation,and reasonable guidance of insured personnel.Conclusion:Hospitals should take the initiative to establish a self-regulatory mechanism for medical insurance in the hospital,implement comprehensive management of the entire process of medical insurance funds,improve the level of refined management of medical insurance,ensure the safe use of medical insurance funds,and promote the high-quality development of medical institutions.

关 键 词：医保基金 基金监管 医疗保险 根本原因分析法 医保管理 

分 类 号：R197[医药卫生—卫生事业管理]