医保限定性药品拒付原因

Health Limiting Drug Refusal Reason

目的从医保限定性药品拒付数据入手,分析社保经办机构对定点医院违规使用医保限定性药品发生医保基金拒付的原因,提出解决的对策。方法通过对新疆乌鲁木齐市4家二级医院2014年医保拒付数据进行分析,运用德尔菲法分析医保限定性药品拒付的原因。结果该院医保医师因违规使用医保限定性药品导致的拒付病例数占全年医保违规拒付病例数的65.17%。结论定点医疗机构应该加大对医保政策的宣教力度,全力推进医院数字化、信息化建设,加强医保违规问题的事前监控,持续改进医保智能审核系统,避免医院医保基金拒付事件的发生。

Objective Based on refusal payment data on assigned drugs of medical insurance with limitation, analyze the reason why social security administration department refuse to pay the drugs assigned by medical insurance in designated hospital, and put forward the measures. Methods Through the health care refusal payment data about four secondary hospitals in Xinjiang in 2014, analyze the reason for the refusal payment by using Delphi method. Results The refusal payment cases because of health care physicians using the assigned drugs with limitation against the rules accounted for 65.17% in annual medical insurance payment refusal cases. Conclusion Designated medical institutions should strengthen the propaganda and education about medical insurance policies, and promote hospital digitalization and informatization, monitor the problems in advance, and continuously improve the medical insurance intelligent approval system to avoid the refusal payment of the hospital＇s medical insurance fund.