智能化在医院医保控费管理中的应用研究

目的:运用医保智能化管理在提高医院医疗服务质量、维护医保基金安全,提升基金绩效的实践中获得显著成效。方法:医院配合医保经办管理部门构建事前提醒、事中自律和事后分析的涵盖医保、医院和医生各层面的立体监控体系,并同时建立一套适合自身的医保智能化控费管理系统,包括辅助用药和抗菌药物的管理、完成医保办的各类医保控费指标和高值耗材的管理等。结果:全院药占比由2016年的38.59%下降到2018年的30.12%;医保住院病人人均费用逐年下降;结论:该医保控费体系统具有可行性。

Application of intelligent medical insurance managemen in the hospital

Objective:To use the intelligent management of medical insurance in the hosipital to achieve remarkable results among improve the quality of hospital medical services,maintaining the health insurance fund security and improve fund performance.Methods:The hospital has cooperated with the management department of medical insurance to establish a three-dimensional monitoring system.It includes prereminder,self-discipline in the process and post-hoc analysis,coveringmedical insurance,hospitals and doctors at all levels.At the same time,the hospital has also built a intelligent system suitable for its own to control medical expense system by medical insurance,which includes the management of the characteristics of antibiotics and adjuvant drugs、completion the targets of all kinds of control medical expense by medical insurance department and the management of high value consumable ect.Results:The medicine expenditure of the whole hospital has decreased from 38.59%in 2016 to 30.12%in 2018.The average expenses of medical in⁃surance per person-time were falling everyyear.Conclusions:The system to control medical insurance expense is feasible.