从异地医保病案核查浅谈异地就医管理

Discussion on the Management of Long-distance Medical Treatment from the Medical Record Verification of Long-distance Medicare Insurance

目的通过对某院接收异地医保核实病案的分析,针对异地就医骗保行为,从医保经办机构、异地就诊医院及患者三方面提出合理化建议,减少骗保行为的发生,确保医保基金的安全。方法用Excel表对2016年某院接收异地医保核实病案进行分析、整理,统计病案核查不符合率、患者参保省份及患者在某院就诊科室的分布构成。结果 2016年某院接收异地医保核实病案1425份,其中有45份病案核查结果不符,不符合率为3.16%,异地患者集中来源于河北省、内蒙古自治区、山东省、山西省、黑龙江省,5个省份患者占总核实病案总数的79.41%。在某院的就诊科室主要是神经内科、神经外科及功能神经外科,3个科室的患者占总核实病案总数的64.93%。结论加快推进医保全国互联网建设,重点加强与参保人员集中省市医保经办机构的协议管理,建立异地就医费用核查制度,异地就医医院加强病案信息监管,严格核实患者身份信息,可以有效减少骗保行为的发生。

Objectives Through the analysis on the medical record verification of long-distance medicare insurance of our hospital, to put forward reasonable suggestions and different hospital patients from three aspects aimed at the cheat insurance behavior, so as to reduce the potentially fraudulent behavior and ensure the safety of the medical insurance fund. Methods The Excel table was used to analyze and sort out the medical records obtained by our hospital in 2016, and to check the rate of the medical records, the rate of non compliance, the distribution of the insured provinces and patients in our hospital. Results The hospital received 1425 cases of different health check medical records in 2016,, including 45 copies of medical record verification results, not coincidence rate was 3.16%, the patients with different focused from Hebei, Shandong, Shanxi, Inner Mongolia autonomous region,Heilongjiang province, five provinces in patients with total medical record 79.41% of the total number of verification.In one hospital, the department was mainly neurology, neurosurgery and functional neurosurgery, and the patients in 3 departments accounted for 64.93% of total verified cases. Conclusions We should accelerate the establishment of medicare national internet, focus on strengthening the management and centralized insured agreement provinces health insurance agencies, establish off-site medical expenses check system, remote medical hospital medical record information supervision, strictly verify the identity of patients, could effectively reduce the occurrence of potentially fraudulent behavior.