院端医保智能审核系统应用实务研究  

Practical Research on the Application of Hospital-end Medical Insurance Intelligent Audit System

作　　者：程玉敏 黄凤明 CHENG Yumin;HUANG Fengming(The First Affiliated Hospital of USTC,Hefei 230001,Anhui,China)

机构地区：[1]中国科学技术大学附属第一医院,安徽省合肥市230001

出　　处：《中国卫生信息管理杂志》2023年第5期792-796,共5页Chinese Journal of Health Informatics and Management

摘　　要：目的 实现医疗机构医疗服务行为的规范管理及提前干预,规范医生诊疗行为,改变被动医保拒付处罚的处境。方法 以安徽省某三甲医院为例,运用案例研究法探索医疗机构院端医保智能审核系统的应用实践。结果 通过院端医保智能审核系统实时监测医院病例数据,对医疗服务行为开展事前预防、事中监管、事后核实全流程管理,对不合理医疗费用做到主动发现、干预提醒、分类处置。结论 通过提高院端智能审核系统的集约化,完善智能审核规则,提高智能审核系统结果导向性,可推进医院医保规范化管理,助力医院高质量发展。Objective To realize the standardized management and early intervention of medical service behaviors in medical institutions,standardize doctors' diagnosis and treatment behaviors,and change the situation of passive non-payment of medical insurance.Methods Taking a third Class A hospital in Anhui Province as an example,the case study method is used to explore the application practice of the hospital-end medical insurance intelligent audit system in medical institutions.Results The intelligent audit system of hospitalend medical insurance was established to monitor hospital case data in real time,carry out whole-process management of pre-prevention,in-process supervision and post-verification of medical service behaviors,and proactively discover,intervene and remind,and classify unreasonable medical expenses.Conclusion By improving the intensification of the hospital-end intelligent audit system,perfecting the intelligent audit rules and improving the result-oriented of the intelligent audit system,the hospital-end intelligent audit system can be further improved,jointly promote the standardized management of hospital medical insurance and help the highquality development of the hospital.

关 键 词：医疗机构 医保基金监管 智能审核系统 

分 类 号：R-058[医药卫生] R197.3