摘要
目的探讨DRG支付改革形势下医院医保基金的监管情况,促进医疗服务行为持续改进。方法通过分析上海市某三级专科医院2021年医保审核情况,明确医保拒付原因,提出改进对策。结果2021年医保审核条目12665条,医保拒付条目2693条,医保拒付金额1804967元。医保拒付条目数较多的项目有违规收费(42.8%)、医用耗材审核问题(20.4%)、超限定频次(19.6%)和超限定范围用药(11.6%),医保拒付金额最多的项目为违规收费(123900元)。结论医院可从组织、管理、技术和经济4个层面规范医疗服务行为,以适应DRG改革形势下的医保监管要求,促进医院健康可持续发展。
Objective To explore the supervision of hospital medical insurance fund under the situation of DRG payment reform,and improve the use efficiency of medical insurance fund.Methods By analyzing the medical insurance audit of a tertiary specialized hospital in Shanghai in 2021,the reasons for medical insurance refusal were clarified and the countermeasures for improvement were put forward.Results In 2021,there were 12665 hospital medical insurance review entries,2693 medical insurance denials,1804967 yuan in medicare denials.The items with the highest number of denials were illegal charges(42.8%),medical consumables review(20.4%),over-limit frequency(19.6%)and over-limit medication(11.6%).Among them,the item with the highest amount of rejection by the mesical insurance was illegal charges(123900 yuan).Conclusion Hospitals can standardize medical insurance service behavior from the four levels of organization,management,technology and economy,so as to adapt to the requirements of medical insurance supervision under the situation of DRG reform and promote the healthy and sustainable development of hospitals.
作者
何琼
刘晨红
HE Qiong;LIU Chenhong(Obstetrics and Gynecology Hospital Affiliated to Fudan University,Shanghai,200011,China;不详)
出处
《中国卫生质量管理》
2023年第8期68-70,74,共4页
Chinese Health Quality Management
基金
上海申康医院发展中心管理研究项目(编号:2020SKMR-40)。
关键词
DRG
医保监管
医保拒付
医保基金
三级专科医院
Diagnosis Related Group(DRG)
Medical Insurance Supervision
Medical Insurance Denied Payment
Medical Insurance Fund
Tertiary Specialized Hospital
作者简介
通信作者:刘晨红:复旦大学附属妇产科医院医保办公室主任,E-mail:liuchenhong66@163.com。
