商业保险直接理赔在高端医疗服务中的使用

目的:了解商业医疗保险直接理赔业务使用情况及存在问题,为建立上海商业医疗保险新模式提供科学依据。方法:对复旦大学附属华山医院国际医疗中心2010年商业保险使用情况进行专项调查。结果:2010年该中心病人保险直接理赔的金额比例达35.9%;其中每月住院直接理赔收入占总住院收入的比例为33.5%,门诊直接理赔收入占门诊总收入的比例为39.8%;每月住院病人的保险直接理赔人次比例达62.2%,门诊人次比例为32.5%,住院高于门诊,但保险直接理赔的住院病人均次费用较非保险直接理赔病人的人均次费低。结论:商业保险直接理赔在高端医疗服务市场中有大量的需求,政府对商业保险提供方及高端医疗服务提供方的政策扶持,医疗服务方和保险提供方的优质服务,使商业保险直接理赔在高端医疗服务中使用更广更便捷。

The application of the commercial insurance direct-billing in premium healthcare

Objective： To Understand the situation and problems of commercial medical insurance direct-billing and to provide a basis for the establishment of a new medical insurance system. Methods： A special investigation of commercial insurance direct-billing was conducted at Huashan Worldwide Medical Center （HWMC）, Huashan Hospital, Fudan University in 2010. Results： The proportion of direct-billing revenue in total revenue was 35.9%, 33.5% for in-patient and 39.8% for out-patient revenue respectively. The proportion of direct-billing inpatient cases in total cases per month was 62.2%, much higher than that of out-patient with 32.5% per month, but the average expenditure for direct-billing was higher than that of non-direct-billing cases. Conclusion： There was a high request of commercial insurance direct-billing in premium healthcare. Commercial insurance direct-billing will be used widely and more convenient in premium healthcare with the policy support of government and quality service from medical providers.