医院商保“一站式”结算平台的设计与应用  

Design and Application of an End-to-end Commercial Health Insurance Claims Platform in Hospital

作　　者：鄂恒 沈岚[1] 陈倩倩 E Heng;SHEN Lan;CHEN Qianqian(Renmin Hospital of Wuhan University,Wuhan 430060,Hubei,China)

机构地区：[1]武汉大学人民医院,湖北省武汉市430060

出　　处：《中国卫生信息管理杂志》2024年第3期393-398,共6页Chinese Journal of Health Informatics and Management

摘　　要：目的解决商业健康保险报销“理赔难、手续繁、报销慢”的问题,提升医疗服务效率,改善医院商保患者的就医体验。方法在确保信息安全的前提下,建立统一的接口标准和服务流程,实现医院、医保、商保的数据联通,打通医院和保险公司之间的数据孤岛。结果武汉市某三级甲等医院成为湖北省首家成功构建商保“一站式”结算平台的医院,实现医院就诊患者出院时医保、商保和自付的“一窗口”“一站式”结算。结论提供商保“一站式”结算服务是医院通过“互联网+医疗健康”推进便民惠民服务、改善患者服务体验的重要举措,大幅节省了商保患者的时间和精力,实现了商保患者“看病结算最多跑一次”的目标。Objective To improve the efficiency of medical service and the medical experience of patients with commercial health insurance,aiming at the problems of"difficult claim settlement,complicated procedures and slow reimbursement".Methods Under the premise of ensuring information security,a unified interface standard and service process were established to realize data connectivity among hospitals,medical insurance and commercial insurance,and to open up data islands between hospitals and insurance companies.Results It became the first hospital in Hubei Province to successfully build the first end-to-end health insurance claims platform,and realized the"one-window"and"one-stop"settlement of medical insurance,commercial insurance and self-payment when hospital patients were discharged.Conclusion Provider commercial insurance"one-stop"settlement service is an important measure for hospitals to carry out convenient and beneficial services through"Internet+medical health"and improve patient service experience,which greatly saves the time and energy of commercial insurance patients,and achieves the goal of"maximum one visit to the doctor and settlement"for commercial insurance patients.

关 键 词：商业健康保险 互联网+医疗健康 医疗保障 “一站式”结算平台 商保直赔 

分 类 号：R-058[医药卫生] R319