某省医保结算清单管理存在的问题及对策分析  

Problems and countermeasures of the management of medical insurance settlement list in a province

作　　者：石艺 李瑞佳 栾丽华 Shi Yi;Li Ruijia;Luan Lihua(Department of Medical Records Management,Yan′an Hospital of Kunming City,Kunming 650051,China;Department of Medical Service Management,Yunnan Provincial Healthcare Security Administration,Kunming 650041,China;Office of Medical Insurance,Yan′an Hospital of Kunming City,Kunming 650051,China)

机构地区：[1]昆明市延安医院病案管理科,昆明650051 [2]云南省医疗保障局医药服务管理处,昆明650041 [3]昆明市延安医院医保办,昆明650051

出　　处：《中华医院管理杂志》2024年第12期977-980,共4页Chinese Journal of Hospital Administration

摘　　要：医保结算清单的规范化管理是保障医保基金合理使用的重要举措。2024年3月,本研究结合有关医保基金结算清单管理的专家访谈,以及对某省46家按DRG付费定点医疗机构的实地调查结果,总结了医保结算清单在设计、实施及推广过程中存在的问题,包括填报项设计未完全满足实际需求,数据采集格式不统一,定点医疗机构的主体责任和工作流程不够明确,各地的填报规范及信息接口规范不统一,医保结算清单功能较局限,缺少统一的事前校验规则以及配套制度不完善。针对这些问题,提出加强医保结算清单的规范化和标准化设计,明确医保结算清单的主体责任,拓展医保结算清单的功能,增设前置质控规则和完善配套制度等应对策略,以期为推进我国医疗机构医保结算清单的规范化管理提供参考。The standardized management of medical insurance settlement list is very important to ensure the rational use of medical insurance funds.In March 2024,this study summarized the problems in the design,implementation,and promotion of the medical insurance settlement list based on expert interviews on the management of the medical insurance fund settlement list,as well as on-site investigations of 46 designated medical institutions in a province.These issues included incomplete design of reporting items that do not fully meet actual needs,inconsistent data collection formats,unclear main responsibilities and workflow of designated medical institutions,inconsistent reporting and information interface standards across regions,limited functionality of medical insurance settlement lists,lack of unified pre verification rules,and incomplete supporting systems.In response to these issues,this study proposed to strengthen the standardization and design of the medical insurance settlement list,clarify the main responsibilities and expand the functions of the list,add pre quality control rules,and improve supporting systems,so as to provide references for promoting the standardized management of medical insurance settlement lists in medical institutions of China.

关 键 词：医疗保障 医保结算清单 医疗机构 疾病诊断相关分组 现存问题 对策分析 

分 类 号：R197.32[医药卫生—卫生事业管理]