论文部分内容阅读
医疗保险的审核工作是医疗保险中的一个极其重要环节,但同时也是一个难点问题,因为这既关乎患者的切身利益,同时也关系到医保基金的合理支出和承受能力[1]。自2013年起,杭州市医疗保险管理服务局对各定点医疗机构的医保费用,实行从人工抽查审核过渡到计算机辅助全面审核的模式。人工抽审,由于各审核人员的医学专业知识不同,随机抽审内容、审核尺度不一,对医疗机构的费用审核存在一定差异性。而实施计算机辅助审核医保费用后,对各级医疗机构公平公正,统一审核规则,按月审核,对问题单据进行批量剔除。逐步放入审核规则,对医保费用实时监控;对部分违规费用预先结算提醒、报错;部分违规费用事后剔除。医保管理由粗到细,达到控费和提高医疗服务质量双赢。目前已取得较好的效果,更好的管理了医保费用,后续有向其他省市进一步推广的趋势。为适应医保改革制度的要求,医院必须建立高效安全的医疗保险计算机管理系统和规范的医保从业人员。为此,医院医保办快速执行医保政策,有效地提高医院医保管理水平。
The review of medical insurance is an extremely important part of medical insurance, but it is also a difficult issue at the same time because it concerns the vital interests of patients as well as the reasonable expenses and affordability of medical insurance funds [1]. Since 2013, Hangzhou Medical Insurance Administration Service has implemented the mode of transition from manual examination to computer-aided comprehensive examination for the medical insurance fees of medical institutions at designated locations. Manual sampling, due to the different medical professional knowledge of different auditors, random sampling content, audit scales vary, there are some differences in the audit of the cost of medical institutions. After implementing the computer-aided examination of medical insurance fees, the medical institutions at all levels are fair, just and uniformly audited, and monthly reviews are conducted to eliminate the issue documents in batches. Gradually into the audit rules, real-time monitoring of medical insurance costs; pre-settlement reminder of some violations of fees, error; part of the illegal fees were removed afterwards. Health care management from coarse to fine, to control fees and improve the quality of medical services win-win situation. Has achieved better results, better management of the medical insurance costs, follow-up to other provinces and cities to further promote the trend. In order to meet the requirements of the health care reform system, the hospital must establish a highly effective and safe medical insurance computer management system and a standardized health insurance practitioner. To this end, the hospital Medicare Office quickly implement the health insurance policy, effectively improve the hospital’s health care management.