常态化监管体系下医保智能监控应用现状及优化策略研究  

Research on Current Application and Optimization Strategy of Medical Insurance Intelligent Monitoring System Under Normal Supervision

作　　者：符美玲[1,2] 陈锦 张伟 孙玉梅[1] 刘英[1] 陈艺[4] 肖明朝 陈登菊[1] 

机构地区：[1]重庆医科大学附属第一医院,重庆400042 [2]华中科技大学同济医学院医药卫生管理学院,武汉430030 [3]陆军军医大学第二附属医院,重庆400037 [4]重庆市妇幼保健院,重庆401147

出　　处：《中国医疗保险》2024年第6期73-80,共8页China Health Insurance

基　　金：重庆市教委人文社会科学研究项目“基于委托代理理论的疾病诊断相关分组医保支付制度对医疗服务供方行为的影响研究”(23SKGH044);2022年重庆医科大学附属第一医院管理基金“DRG支付制度下医院医疗服务监管体系的构建研究”(GLJJ2022-01);2022年重庆医科大学附属第一医院管理基金“医疗服务价格全流程智能审核系统在临床计费管理中的应用研究”(GLJJ2022-05)。

摘　　要：常态化监管体系下,面对医保监管对象众多、资金量庞大、结算数据海量的新形势、新挑战,医保智能监控成为基金监管的必备工具、重要手段及技术支撑。本文通过梳理回顾国家医保局成立以来的常态化监管新举措,分析医保智能监控的必要性和意义;以某省(市)为例,应用专家访谈法及问卷调查法调查统筹区医保经办机构的智能监控手段应用现状;提出构建我国医保智能监控体系及推进地区应用的优化策略。Under the normal supervision system,facing the new situation and challenges of numerous medical insurance supervision objects,huge amount of funds and massive settlement data,medical insurance intelligent monitoring is an essential tool,important means and technical support for medical insurance fund supervision.This paper reviews the new measures of medical insurance regular supervision since the establishment of the National Healthcare Security Administration,and analyzes the necessity and importance of medical insurance intelligent monitoring.Taking a provincial administrative region as an example,this paper investigates the current application of the medical insurance intelligent monitoring system with expert interview and questionnaire survey,and puts forward suggestions on the construction of the medical insurance intelligent monitoring system in China and the promotion of regional applications.

关 键 词：医疗保障 基金监管 智能监控 

分 类 号：F840.684[经济管理—保险] C913.7[社会学]