惠州市三级医院住院病人医保结算政策分析.pdfVIP

现代医院2016 年9 月第 16 卷第9 期医院管理菊 Modern HospiωSep 2016 Vol16 No 9 1369 惠州市三级医院住院病人医保结算政策分析 叶飞跃陈晓红简希尧肖俊辉 [摘 要] 当前，惠州市存在居民医保病人难住院就诊，医院选择性收治病人，医院医保结算亏损严重等的问 题。笔者参考某医院医保结算实际运营数据，针对惠州市三级医院住院病人医保结算政策，分析存在的问题，找出根 源，提出惠州市三级医院住院病人医保结算政策的对策思路，使群众看上病、看好病，促进医院的可持续发展。 [关键词] 惠州市;医保结算;政策 中固分类号: R197 文献标识码: B doi: 1O.3969/j. issn.1671-332X.2016.09.045 Analysis of Inpatient Medical Insurance Se创ement Policy in Ter伽ry Hospitals in Huizhou YE Fei阳， CHEN Xiω，Jwng ， JIAN Xi抖。， et αl [ Abs!ract) CurrenÙY , such issues come into being as difficulty of Huzhou residents with medical insurance in medical consultation and hospitalization , hospital s selection in admitting resident patients and huge loss in medical insurance settle- ment in hospital. The au出ors tηto find a way out by referring to the actual operation data from a hospital and aiming at Huizhou medical insurance settlement policy. They put forward the countermeasures , which may ensure the resident an easy access to medical consultation and promote the hospital s sustainable developmenl. {问Ke叼yw附or呻d由叫s叶) Hu也讪u山归且且i蛐z址油hO\町 Medical Insl缸uran阳c倪eS灿et甜t忧tl阳eme毗n时盹t; Policy [Authors addr四s) Third People s Hospital of Huizhou , Huizhou 516∞2 ， China 2015 年7 月，惠州市住院病人医保结算政策进 定额和定额人次返拨医保费用，超定额由医院承担， 行重大改革。某医院属于三级综合性大医院，业务 结余归医院，超定额费用进入年终清算。否则，进入 量在惠州市排名第二，解决了惠州市十分之一的医 超3 倍定额医保结算，社保局每月按人次返拨 1 个 疗需求，但约 60% 的就诊病人属于惠州医保病人。 定额，按每人次留存2 个定额进人年终结算，同时超 医保结算政策改革前，某医院住院病人医保结算总 3 倍部分的费用按959毛进行返还给医院，5%部分无 亏损额占政策内总费用的比例低，约1. 7% ，医保亏 法返还。年终清算额为3 倍内超定额费用和超3 倍 损额属于医院运营可接受范围之内。改革后，医院 2 个