医院医保基金使用政策回顾及典型问题与改进策略探讨

Policy Review,Typical Problems and Improvement Strategies on the Use of Medical Insurance Funds in Hospitals

通过回顾医保基金监管相关政策,结合打击欺诈骗保专项治理以来,国家医保局和地方医保局通报的医院违规使用医保基金典型案例,分析了医院违规使用医保基金行为的主要类型。建议医院从以下四个方面提高医保基金使用效率的策略:转变观念,树立法治思维,自觉维护医保基金的安全;强化培训,规范诊疗行为,从源头防范不合理收费风险;完善制度,强化内部控制,建立合规收费长效管理机制;技术支持,应用智能审核,事前、事中、事后监控收费。

Medical insurance is a work related to residents’health and well-being.In order to promote the reform and development of medical security,it needs guide hospitals to make effective use of"life saving money".It reviews the relevant policies on the supervision of medical insurance funds,and analyzes the main types of illegal use of medical insurance funds by hospitals in combi-nation with typical cases reported by National Medical Insurance Administration and Local Medical Insurance Administrations since the special campaign against fraud.It is suggested that hospitals should improve the use efficiency of medical insurance funds from the following four aspects:change the concept,set up the rule of law thinking,and consciously maintain the safety of medical insurance funds;strengthen the training,standardize the diagnosis behavior,prevent the risk of unreasonable charge from the source;improve the system,strengthen the internal control,establish compliance charges long-term management mechanism;technical support,application of intelligent audit,monitoring charges before the process,during the process,and after the process.