基于精细化管理的跨省医保结算流程再造

Reconstruction of Inter-provincial Medical Insurance Settlement Process Based on Lean Management

目的通过建立有效协作机制,规范临床医疗行为,优化医保管理环节,构建高效准确的异地就医直接结算流程。方法通过对业务流程关键点的分析,设计并实施管控措施,再比较异地结算情况的变化。结果异地患者结算等待时间缩短,结算率提高,患者满意度改善,达到预期效果,住院次均费用和个人负担也合理性下降。结论医院通过精细化管控医疗和医保管理环节,提高了服务效率和质量,让患者更便捷地享受异地直接结算政策的红利,保障医保基金的有效使用。

Objective Through establish an effective and cooperative mechanism to standardize clinical medical behavior,optimize medical insurance management,and construct an efficient and accurate direct settlement process for medical treatment in different places.Methods Through the analysis on the key points of the business process,we designed and implemented the control measures,and then compared the changes of settlement status.Results The waiting time for settlement of patients in different places was shortened.The settlement rate was improved.Patient satisfaction was improved,and the expected effect was achieved.The average cost of hospitalization and personal burden were also reduced.Conclusion Through lean management of the medical management process and medical insurance management process,the service efficiency and quality was improved.It also accessed patients to he bonus of the direct settlement policy in different places and ensured the effective use of the medical insurance fund.