肿瘤专科医院医保控费信息化管理措施及成效分析

Medical Insurance Expense Control with Informationized Management in Cancer Hospital

[目的]探讨信息化管控措施对医院医保控费的影响,规范医院基本医疗保险基金的使用,提高基金的使用效率。[方法]利用医院医保信息化管控平台对医院收费系统进行全方位监管,分析我院监管前后医疗费用增长幅度、医保总额预算费用控制指标完成情况、医保拒付率等数据,并利用Wilcoxon符号秩检验方法对比监管前后医保拒付条目和医保拒付率的差异。[结果] 2017年各项指标均比2015年有所下降,医保拒付率从2015年的0.70%下降至2017年的0.56%,拒付条目下降26.5%(P=0.01)。[结论]加强医保控费信息化管理有助于规范基本医疗保险基金的使用,有助于医院健康可持续的发展。

[Purpose]To analyze the effectiveness of informationized management for the medical insurance expense control in cancer hospital.[Methods]The charging system has been monitored by medical insurance expense informationized platform in our hospital in an all-round way since 2016.The increase of medical expenses ,the control index of medical insurance budget and the refusal of medical insurance were compared before and after monitoring system set up with Wilcoxon symbolic rank test.[Results]All expense indexes in 2017were lower than those in 2015.The refusal rate of medical insurance dropped from 0.70% in 2015to 0.56% in 2017.The number of refusal items decreased by 26.5%(P=0.01).[Conclusion]The informationized management system strengthens the medical insurance expense control and facilitates the standardized use of insurance fund,and are also conductive to the healthy and sustainable development of the hospitals.