摘要
目的:优化医院医保管理流程,规范医生的医疗行为和患者的就医行为,从而减少医保拒付费用,保障医保基金的合理使用。方法:统计北京大学第一医院近2年门诊医保拒付数据,并进行描述性分析,加强医保拒付防控管理后,再对比门诊医保拒付数据的变化。结果:实施管控措施后,医保拒付减少,达到预期效果,城镇职工和居民医保的门诊次均费用、药占比也合理下降。结论:医保拒付涉及医院管理、医疗和患者等多方面原因,医院医保管理部门应充分利用信息化技术,优化管理流程,精细化管理环节,动态跟进政策变化,不但能降低门诊医保拒付费用,还可以改善其他门诊医保控费指标。
Objective： To improve the process of the medical insurance management in hospitals, regulate the medical practices provided by doctors and the healthcare seeking behavior of patients, so as to reduce the probability of medicare, payment refusal and ensure the rational use of medical insurance fund. Methods： Data about the outpatient payment refusal in recent 2 years was collected and studied by descriptive analysis. After the preventive measures had been implemented, it compared the data of the outpatient payintent refusal before and after the management improvement. Results： The incidence of the outpatient medicare payment refusal was reduced and met the expectation after the implement of administration and control measurement. The average cost of urban employees and urban residents had been rationally decreased accordingly. Conclusion： The medical insurance payment refusal was involved with hospital administration, medical practices and patients. Hospital medical insurance management department should make full use of in- formation technology to optimize the process and refine management links, and follow up policy changes dynamically, which couht not only reduce outpatient medical insurance payment refusal incidence, but also improve other outpatient medical insurance management indicators,
出处
《中国卫生经济》
北大核心
2016年第10期32-35,共4页
Chinese Health Economics
关键词
医疗保险
门诊病人
实时结算
拒付
medical insurance
outpatient
real time settlement
payment refusal
