[1]李木高伟王泽阳刘新平崔有文.医保基金智能监管平台构建与应用[J].中国卫生质量管理,2022,29(12):014-18.[doi:10.13912/j.cnki.chqm.2022.29.12.04 ]
 LI Mu,GAO Wei,WANG Zeyang.Construction and Application of Intelligent Supervision Platform of Medical Insurance Fund[J].Chinese Health Quality Management,2022,29(12):014-18.[doi:10.13912/j.cnki.chqm.2022.29.12.04 ]
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医保基金智能监管平台构建与应用
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《中国卫生质量管理》[ISSN:1006-7515/CN:CN 61-1283/R]

卷:
第29卷
期数:
2022年12期
页码:
014-18
栏目:
特别关注
出版日期:
2022-12-28

文章信息/Info

Title:
Construction and Application of Intelligent Supervision Platform of Medical Insurance Fund
作者:
李木高伟王泽阳刘新平崔有文
河北省人民医院
Author(s):
LI MuGAO WeiWANG Zeyang
Hebei General Hospital
关键词:
医保基金智能监管监管平台闭环管理信息化
Keywords:
Medical Insurance Fund Intelligent SupervisionSupervision PlatformClosed-Loop Management Informatization
分类号:
R197.324
DOI:
10.13912/j.cnki.chqm.2022.29.12.04
文献标志码:
B
摘要:
为确保医保基金合理、规范使用,以医保政策性要求为依据,利用信息化手段,构建了医保基金智能监管平台。通过构建医保审计规则库与知识库,开展医保智能审核,以事前提醒、事中监管、事后稽核方式,实现了全过程实时监管,减少了违规医疗行为发生,提高了医保基金的使用效率。完善规则库分层级管理,建立多模型融合监控体系,提高智能监管系统与临床诊疗系统的集成水平等,应是医保基金智能监管的发展方向。
Abstract:
In order to ensure the reasonable and standardized use of medical insurance fund, based on the policy requirements of medical insurance, the intelligent supervision platform of medical insurance fund was constructed by means of information technology. Through the construction of medical insurance audit rule base and knowledge base, the intelligent audit of medical insurance was carried out, and the real-time supervision of the whole process was realized by means of pre-warning, in-process supervision and post-audit, which reduced illegal medical behaviors and improved the efficiency of the use of medical insurance fund. It is believed that the development direction of intelligent supervision of medical insurance fund will be to improve the hierarchical management of rule base, establish a multi-model fusion monitoring system, and improve the integration level of intelligent supervision system and clinical diagnosis and treatment system.

参考文献/References:

[1]丁 涛,郭 冬.医院信息化医保控费研究[J].卫生经济研究,2021,38(10):77-79. [2]陈在余,张子桐,朱娇娇.城乡医保普及对居民医疗费用控制的影响分析[J].中国卫生经济,2021,40(1):49-52. [3]曲建卫,张析哲,彭宏宇,等.某院综合改革对医疗费用结构与直接医疗经济负担的影响研究[J].中国卫生质量管理,2020,27(3):43-46. [4]国务院.医疗保障基金使用监督管理条例:国令第735号[EB/OL].(2021-02-19)[2022-02-20].http://www.gov.cn/zhengce/content/2021-02/19/content_5587668.htm. [5]周 彬,程 超,童俊东,等.基于智能审核的医保病种控费模型设计与探索[J].中国医院管理,2019,39(12):61-62. [6]韩 栋,卢弘栩,吴丽萍,等.智慧医保病种控费系统在医院管理中的应用研究[J].中国数字医学,2020,15(1):92-94. [7]国家医疗保障局.关于印发《医疗保障基金智能审核和监控知识库、规则库管理办法(试行)》的通知:医保发〔2022〕12号[EB/OL].(2022-03-30)[2022-04-15].http://www.gov.cn/zhengce/zhengceku/20 22-04/08/content_5684118.htm.

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更新日期/Last Update: 2022-12-28