摘要
近年来国家医保支付政策由项目付费制改为总额预付制,医保管理部门对医院的考核方式也相应变为同时考核医疗质量指标和医保总额费用控制指标。研究结合某三甲医院医保费用管理及结算的工作实践,阐述总额预付制在实施过程中遇到的问题,包括保证医疗质量和控制医疗费用的矛盾;审核与监督机制有待相应完善等问题。并提出解决上述问题的一系列精细化管理措施,包括完善医院的基本医保管理规定、规范诊疗行为、加强医保控费政策的宣传及培训、加强医保病案质量管理、建立健全医保费用结算和审核流程、建立医保费用结算申报和支付数据库等措施。经过一系列精细化的管理,实现了总额预付制的制定初衷,达到了在保证医疗服务质量的前提下控制医疗费用的目标。
In recent years,the national medical insurance payment policy has changed from the project payment system to the total prepayment system,and the evaluation method of the medical insurance management department on the hospital has also changed to simultaneously evaluate the medical quality index and the total medical insurance cost control index.Based on the work practice of medical insurance cost management and settlement in a tertiary hospital,this article explains some of the problems encountered in the implementation of the total prepayment system,including:the contradiction between ensuring medical quality and controlling medical expenses;the review and supervision mechanism needs to be improved accordingly.And put forward a series of refined management measures to solve the above problems,including:perfecting the basic medical insurance management regulations of the hospital;standardizing the diagnosis and treatment behavior;strengthening the publicity and training of the medical insurance cost control policy;strengthening the quality management of medical insurance medical records;establishing and improving the settlement of medical insurance costs.Review process;measures such as establishing medical insurance expense settlement declaration and payment database.After a series of refined management,practice has proved that the original intention of the total prepayment system has been realized,and the goal of controlling medical expenses under the premise of ensuring the quality of medical services has been achieved.
作者
孙燕
朱倩
Sun Yan;Zhu Qian(Xuanwu Hospital of Capital Medical University,Beijing 100053,China;不详)
出处
《中国病案》
2021年第9期22-24,共3页
Chinese Medical Record
基金
北京市医院管理局科研培育计划项目(PG2018011)。
关键词
总额预付
病案管理
费用审核
Total prepayment system
Medical record management
review expenses
