医保门诊实时结算费用拒付分析及应对措施.pdfVIP

《中国卫生经济》第35卷第10期{总第404期) 2016年10 月 口医疗保障 医保门诊实时结算费用拒付分析及应对措施 叶小巾①，程苏华①，孟军①，邢建丽① 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 门诊医保拒付戴据的变化。结果:实施管控措施后，医保拒付减少，这到预期效果，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，动态跟迸政策变化，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。 关键词 医疗保险; I‘丁诊病人;实时结算;拒付 中图分类号 R1-9; F840.613 文献标志码 B 文章编号 1003-0743(2016)10-0032-04 001 10.7664/CHE20 161 008 Analysis a nd Countermeasures for Medical Insurance Payment Refu sal in the Real Time Settlement in Outpatient De- partmen tNE Xiao-jin , CHENG Su - hua , MENG J un , et al.llChinese Health Econ omics, 2016,35(10):32-35 Abstract Objective: 10 improve Ihc pro(,ess of Ih e m创lical inslIrance managemenl in hospilals , reglllale Ihe med ical praclices provided by doclors and Ihe healthcare seeking behavior of palienls , 50 a5 10 redllce Ihe probabilily of medicare paymenl refllsal and en- 511 re Ihe ralional lIse of rnedical inslIranee fllnd. Methods: Oala aholll Ihe olllpalienl paymenl refusal in recen l 2 year百 was co)) ecled and sludied by descripli ve analysi~. Afler Ihe prevenlive measures had been implernenled. il compared Ih肝 dala of Ihe olltpalienl pay- menl refusal before and afler Ihe managemenl irnprovement. Results: Th e inci ience of Ihe oulpalienl medicare paymenl refusal was re- dllced and mel Ihe expeclalion afler Ihe implernenl of aclminislralion and eonlrol measurement. Th e average c051 of urban employee5 aml lIrban residenl5 had been ralionally decreased accordingly. Conclusion: rh e medical inSlIrance paymenl refllsal was involved wilh ho~pilal adminiSlration, medical pracli阳s and palienls. Hospilal rn