2020年职工住院医保药品拒付情况分析  

Analysis of the refusal of reimbursement for inpatient medical insurance drugs for employees in 2020

作　　者：索朗拉姆 索朗曲种 泽碧[1] Suolanglamu;Suolangquzong;Zebi(Department of Pharmacy,Tibet Autonomous Region People's Hospital,Lhasa,850000,Xizang,China;Medical Insurance Center,Lhasa,850000,Xizang,China)

机构地区：[1]西藏自治区人民医院药学部,西藏拉萨850000 [2]西藏自治区人民医院医保中心,西藏拉萨850000

出　　处：《西藏医药》2024年第4期5-7,共3页Tibetan Medicine

摘　　要：目的目的为了合理利用医保基金,有效降低医疗保险拒付率,减少医院经济损失。方法方法对我院2020年职工住院医保拒付数据的拒付项目分布、拒付药品分类、拒付原因等进行分析汇总。结果结果2020年我院职工住院医保拒付金额达98.27万,其中药品拒付金额为87.73万,金额占比为89.28%;人血白蛋白等血液代用品、注射用泮托拉唑钠等质子泵抑制剂、注射用生长抑素等抗生长激素类药品拒付金额占拒付总额的60%以上;药品拒付原因大部分为超医保限制适应症,拒付金额占比为85.60%。结论结论针对我院医保拒付现象,医院需加强医保政策宣传与学习力度、加强信息化建设等改进措施,有效减少药品等拒付现象,确保医院资金良性运转。Objective In order to make reasonable use of medical insurance funds,effectively reduce the rate of medical insur-ance refusal and reduce the economic loss of hospitals.Methods The distribution of non-payment items,classification of non-pay-ment drugs and reasons of non-payment were analyzed and summarized in the non-payment data of employee inpatient medical in-surance in our hospital in 2020.Results In 2020,the amount of refused payment was 982,700 yuan,among which,the amount of re-fused payment for drugs was 87.73,accounting for 89.28%;The non-payment amount of blood substitutes such as human blood al-bumin,proton pump inhibitors such as Pantoprazole sodium for injection,and anti-growth hormones such as somatostatin for injec-tion accounted for more than 60%of the total non-payment amount.Most of the reasons for drug refusal were beyond the limit of medical insurance,and the amount of refusal accounted for 85.60%.Conclusion In view of the phenomenon of non-payment of medical insurance in our hospital,the hospital needs to strengthen the publicity and study of medical insurance policy,strengthen the information construction and other improvement measures to effectively reduce the phenomenon of non-payment of drugs and en-sure the benign operation of hospital funds.

关 键 词：医疗保险 药品拒付 分析 

分 类 号：R95[医药卫生—药学]