[1]何琼刘晨红.DRG支付改革形势下的医疗服务行为持续改进[J].中国卫生质量管理,2023,30(08):68-70.[doi:10.13912/j.cnki.chqm.2023.30.8.14 ]
　HE Qiong,LIU Chenhong.Continuous Improvement in Health Care Practice in the context of DRG Payment Reform[J].Chinese Health Quality Management,2023,30(08):68-70.[doi:10.13912/j.cnki.chqm.2023.30.8.14 ]

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DRG支付改革形势下的医疗服务行为持续改进

《中国卫生质量管理》[ISSN:1006-7515/CN:CN 61-1283/R] 卷: 第30卷期数: 2023年08期页码: 68-70 栏目: 医保质量出版日期: 2023-08-15

Title:: Continuous Improvement in Health Care Practice in the context of DRG Payment Reform

作者:: 何琼刘晨红; 复旦大学附属妇产科医院

Author(s):: HE Qiong; LIU Chenhong; Obstetrics and Gynecology Hospital Affiliated to Fudan University

关键词:: DRG; 医保监管; 医保拒付; 医保基金; 三级专科医院

Keywords:: Diagnosis Related Group (DRG); Medical Insurance Supervision; Medical Insurance Denied Payment; Medical Insurance Fund; Tertiary Specialized Hospital

分类号:: R197.5

DOI:: 10.13912/j.cnki.chqm.2023.30.8.14

文献标志码:: B

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12 665条，医保拒付条目2 693条，医保拒付金额1 804 967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（123 900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。

Abstract:: 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. MethodsBy 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.ResultsIn 2021, there were 12 665 hospital medical insurance review entries, 2 693 medical insurance denials, 1 804 967 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(123 900 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.

参考文献/References:

［1］国家医保局.2021年全国医疗保障事业发展统计公报［Z］.2022-06-08. ［2］国务院.医疗保障基金使用监督管理条例［Z］.2021-02-19. ［3］王宇,郑丹桂,蔡月桃,等.医保智能审核在医院管理中的实践和思考［J］.现代医院管理,2020,18(6):72-75. ［4］罗碧眉, 蒋南, 刘建明. 限制性用药政策下医院医保用药管理对策探讨［J］. 医药前沿, 2018, 8(24):371. ［5］理查德·L.达夫特.组织理论与设计［M］.10版.北京：清华大学出版社,2011：15. ［6］童雪君,杨帆,金华岭,等.医院医保管理面临挑战与对策探讨［J］.江苏卫生事业管理,2021,32(12):1616-1618. ［7］吴镝娅,张丽华,刘艳，等.基于DRG的公立医院精细化成本管控实践探讨［J］.中国卫生质量管理,2023,30(1):39-43. ［8］张光耀,朱公建.医院医保基金监管工作的思考［J］.甘肃医药,2021,40(8):753-754，768. ［9］李琦,张雨晴,俞乔.北京市海淀区社区医院的医保拒付原因分析及对策建议［J］.中国卫生经济,2022,41(6):22-25. ［10］滕世伟,李天俊,杨华，等.某三级医院住院医保药品拒付现状分析和管理［J］.医药导报,2022,41（12）：1767-1771. ［11］丁宁,许栋,夏家红，等.DRG支付方式改革下公立医院高质量发展路径探讨［J］.中国医院管理,2023,43(3):81-85. ［12］孟朝琳,蔡源益,吴华章，等.DRGs实施效果评价研究与思考［J］.中国卫生质量管理,2021,28(2):35-38.

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更新日期/Last Update: 2023-08-15