PDCA质量管理工具对降低医保拒付率的效果

Effects of PDCA quality management tools on reducing the chargeback rate of medical insurance

目的分析PDCA质量管理工具对减少医院医保拒付率的效果。方法利用PDCA管理工具,施行长达6年三个阶段的持续质量改进研究项目,分别从信息系统的建设与完善、专职人员的监管、奖惩机制的制定与落实等方面等进行实施与改进。结果医保拒付率从2011年2.12%大幅下降至2018年0.13%,拒付金额从2011年的1254.25万元下降至2018年181.99万元,有效减少了医保拒付费用。结论合理使用PDCA质量管理工具能帮助医院有效规范临床诊疗行为,保障医保基金的合理使用,维护患者的切身利益,持续提高医院医保管理质量及效率。

Objective To analyze the effect of PDCA(plan do check action)quality management tools on reducing the rate of chargeback rate of medical insurance.Methods A continuous quality improvement research project was implemented using the PDCA management tool for six years including three phases,and improved in terms of the construction and improvement of information systems,the supervision of full-time personnel,and the formulation and implementation of reward and punishment mechanisms.Results The rate of medical insurance chargeback dropped sharply from 2.12%in 2011 to 0.13%in 2018,and the amount of chargeback declined from 12.5425 million yuan in 2011 to 18.199 million yuan in 2018,effectively reducing the cost of medical insurance chargeback.Conclusion The rational use of PDCA quality management tools can help hospitals effectively regulate clinical diagnosis and treatment behaviors,ensure the reasonable use of medical insurance funds,safeguard the vital interests of patients,and continuously improve the quality and efficiency of hospital medical insurance management.