医疗保险实时结算的问题与对策

Problem and Solution in Real-Time Medical Insurance Settlement

目的:描述医疗保险实时结算在医院HIS内实施时需要解决的问题。方法:逐个描述具体问题,并给出解决方案。结果:通过解决结算数据不一致、同一药品适应不同报销比例、内外处方标识以及手术材料是否纳入医保报销等问题,保证了医疗保险实时结算在HIS内的顺利实施。结论:为医疗保险实时结算中具有普遍性的问题给出了有效的解决方案,具有较强的现实意义。

Objective To solve the problems encountered in the real-time medical insurance settlement in HIS.Methods The problems were described in details one by one,and the resolutions were provided.Results The real-time medical insurance settlement worked smoothly in HIS based on the effective resolutions to guarantee data consistency,apply different insurance items and determine the prescription or operation material in or out of the insurance scope.Conclusion The effective projects are offered to solve the common problems in real-time medical insurance settlement.