病案稽核医保违规问题及病历质控分析  

Analysis of medical record audit and medical insurance violations problem and medical record quality control

作　　者：童欣[1] TONG Xin(Medical Records Department,Tianjin Central Obstetrics and Gynecology Hospital,Tianjin 300010,China)

机构地区：[1]天津市中心妇产科医院病案科,天津300010

出　　处：《中国城乡企业卫生》2024年第9期217-219,共3页Chinese Journal of Urban and Rural Enterprise Hygiene

摘　　要：现阶段医疗体制改革已逐渐走向成熟,医疗保险市场也得到迅速发展,因此享受医疗保险福利待遇的人员所就诊与住院的比例越来越大。但是在现阶段医疗保险中病案管理仍存着许多问题,需要对此进行解决,以推进医疗保险工作的长久顺利开展。因高额病案存在的医保违规问题涉及数额较大,已经成为医保基金监管工作的重点与难点。通过对某省住院医保高额病案违规问题案件进行分析,明确造成该问题的主要原因。通过分析发现造成住院高额医保病案违规问题频发的根本问题在于医疗机构对经营利益的盲目追求,没有明确医疗服务项目价格与执行标准,部分医疗机构存在对医保政策认知不足的情况等。对于此,相关优化建议应以提高对定点医疗机构的监管为基础,通过医保智能监控的方式提高医保费用监管效率与质量,以此方式完善该地区医疗服务项目,确保就医各项诊疗价格能够完全按照执行标准,同时逐步引入面向医保基金的稽核机制,加强医保对病案监管水平与质量。At present,healthcare system reform has gradually matured,and the medical insurance market has also developed rapidly.Therefore,the proportion of people who enjoy medical insurance benefits seeking medical treatment and hospitalization is increasing.However,there are still many problems in medical record management in current medical insurance,which need to be addressed to promote the longterm and smooth development of medical insurance work.The problem of medical insurance violations caused by high medical records involves a large amount of money and has become a key and difficult point in the supervision of medical insurance funds.By analyzing the case of high medical record violations in a certain province's inpatient medical insurance,the main causes of the problem are identified.Throughanalysis,it was found that the fundamental problem causing frequent violations of high hospitalization medical insurance records lies in the blind pursuit of business interests by medical institutions,the lack of clear pricing and implementation standards for medical service projects,and insufficient awareness of medical insurance policies among some medical institutions.For this,relevant optimization suggestions should be based on improving the supervision of designated medical institutions,and improving the efficiency and quality of medical insurance cost supervision through intelligent monitoring of medical insurance.In this way,the medical service projects in the region can be improved to ensure that all diagnosis and treatment prices are fully in accordance with the execution standards.At the same time,an audit mechanism for medical insurance funds should be gradually introduced to strengthen the level and quality of medical insurance supervision of medical records.

关 键 词：病案稽核 医保违规 病历质控 

分 类 号：R197.323[医药卫生—卫生事业管理]