某院医保基金使用的廉洁风险梳理与防控实践  

Analysis and prevention of integrity risks in the use of medical insurance funds in a hospital

作　　者：杨芳 冯海欢[1] 李天俊[1] 杨华[1] 李耘天 Yang Fang;Feng Haihuan;Li Tianjun;Yang Hua;Li Yuntian(Medical Insurance Office,West China Hospital of Sichuan University,Chengdu 610041,China)

机构地区：[1]四川大学华西医院医保办公室,成都610041

出　　处：《中华医院管理杂志》2024年第1期47-52,共6页Chinese Journal of Hospital Administration

基　　金：四川省科技厅重点研发项目(2021YFS0145);四川省自然科学基金(2023NSFSC1013)。

摘　　要：医保基金是医保制度体系健康运行的基础,关乎百姓福祉、社会稳定。医疗机构作为医保政策落地执行和医保基金使用的重要主体,不断完善和优化自我管理,筑牢医保基金使用廉洁风险防控,既是国家医保基金"严监管"大环境下的必要应对措施,也是医院高质量发展趋势下的必然选择。作者以某医院为例,梳理医保基金使用相关职权目录,分析医生、患者和医保报销审核人员在不同职权运行环节中的廉洁风险点;并介绍医院筑牢医保基金使用廉洁风险防控网格的实践,包括完善医保管理制度,培育持续性廉洁文化,优化流程设计,完善信息系统建设及改进医保服务模式,可为其他医疗机构提供参考。Medical insurance fund is the foundation for the healthy operation of the medical insurance system,which is related to the well-being of the people and social stability.Medical institutions,as important entities in the implementation of medical insurance policies and the use of medical insurance funds,should continuously improve and optimize their self-management,and strengthen the prevention and control of clean risks in the use of medical insurance funds.This is not only a necessary response measure in the context of strict supervision of national medical insurance funds,but also an inevitable choice for hospitals under the trend of high-quality development.This article took a certain hospital as an example to illustrate the practice of sorting out the relevant authority directory for the use of medical insurance funds,analyze the integrity risk points of doctors,patients,and medical insurance reimbursement auditors;And introduced the practice of using a clean risk prevention and control grid to strengthen the hospital′s medical insurance fund,including improving the medical insurance management system,cultivating a sustainable culture of integrity,optimizing process design,improving information system construction,and improving medical insurance service modes,so as to provide reference for other medical institutions.

关 键 词：医疗机构 医保基金使用 廉洁风险 防控实践 

分 类 号：R197.1[医药卫生—卫生事业管理]