基于SOP的医保监管体系完善：以成都市某医院为例

Perfection of medical insurance supervision system based on SOP——Taking a hospital in Chengdu as an example

目的:制定医保管理的标准操作程序,降低拒付费用,提升医院医保管理水平。方法:回顾性分析成都市某医院2017年1月至2018年12月诊疗计费相关拒付费用数据,探讨拒付原因并建立院内医保管理标准操作程序。结果:两年内共计发生拒付1 754例,涉及金额47 553.01元。其中,重复收费频次占比最高,达42.42%;因治疗超限定适应症导致的扣款金额最高,占总金额18.37%。结论:诊疗计费相关拒付问题日益显著,应积极建立医保管理标准操作程序,以保障医保基金稳定运行。

Objective:To formulate standard operating procedure(SOP)for medical insurance management,reduce the refused payment cost,and improve the level of hospital medical insurance management.Methods:Retrospectively analyzed the data on treatment-related and billing-related refused payment from January 2017 to December 2018 in a hospital in Chengdu,explored the reasons for refused payment and established the SOP of medical insurance management.Results:A total of 1754 refused-payment-cases had happened within two years,involving an amount of 47553.01 yuan.Among them,the frequency of repeated charges was the highest,reaching 42.42%.The amount of deductions due to the treatment of no-indications was the highest,accounting for 18.37%of the total amount.Conclusions:The problem of treatment-related and billing-related refused payment is becoming more and more obvious.It is necessary to actively establish a SOP of medical insurance management to ensure the stable operation of the medical insurance fund.