医保智能审核系统的应用与成效分析

Analysis on application and effect about intelligent audit system of medical insurance

医疗费用的快速增长严重威胁着医保基金安全,不合理医疗费用的控制显得尤为重要。近年来,国内开始建设医保智能审核系统,通过制订并实施监控规则,对诊疗过程实行全程监控,对医保利益相关方进行管理约束,从而提高审核效率、规范诊疗行为、控制不合理医疗费用。通过对调研地区数据分析发现,医保智能审核系统在提高医保审核效率、控制医疗费用不合理增长、规范医生诊疗行为和引导患者就医行为方面具有显著效果。在此基础上,提出了完善国内医保智能审核系统的政策建议。

The rapid growth of medical costs is a serious threat to the security of medical insurance fund. Unreasonable medical cost control is particularly important. In recent years, our country began to build medical insurance intelligent audit system, through the development and implementation of monitoring rules to monitor the whole process of treatment. as well to manage the stakeholders of medical insurance. In order to improve the audit efficiency, standardize the diagnosis and treatment behavior, control unreasonable medical expenses. Through the analysis of survey data, the intelligent medical insurance audit system has a significant effect on improving the efficiency of medical insurance audit, controlling the unreasonable growth of medical expenses, regulating the doctor＇s diagnosis and treatment behavior and guiding patients to seek medical treatment. Based on that, this paper puts forward some policy suggestions to improve the intelligent audit system of medical insurance.