高额病案医保违规问题分析——以江苏省某统筹区为例

Analysis of Medical Insurance Violation in High Cost Medical Records——Based on the Practice of An Overall Planning Area in Jiangsu Province

高额病案的医保违规问题因涉及违规数额较大,越来越成为医保基金监管的重点和难点。本文通过回顾性分析江苏省某统筹地区2017年—2019年2048份住院高额病案医保违规问题发生原因,发现住院高额病案医保违规问题频发的主要问题包括:医疗机构对利益最大化的追求、医疗服务项目价格执行说明规定不明确、医疗机构对医保政策认知不足、医保监管能力不足等。下一步,应通过加强对定点医疗机构的协议管理、利用医保智能监控提升医保费用监管效率、完善医疗服务项目价格执行标准、探索引入医保基金第三方稽核机制、强化医保队伍和医护人员能力建设等方式方法,提升医保对高额病案的基金监管水平和效能。

Because of the large amount of medical insurance violations involved in high cost medical records,it is becoming more and more important and difficult for the supervision of medical insurance funds.Based on a retrospective analysis of the causes of medical insurance violations of 2048 inpatient high cost medical records from 2017 to 2019 in an overall planning area of Jiangsu Province,this paper fi nds that the main problems of frequent medical insurance violations of inpatient high cost medical records include the internal management of hospitals is not strict,the price of medical service items is not clear,the medical institutions have insuffi cient cognition of health insurance policies and insuffi cient medical insurance supervision ability.In the next step,we should strengthen the agreement management of designated medical institutions,improve the supervision effi ciency of medical insurance expenses by using medical insurance intelligent monitoring,improve the price execution standard of medical service items,explore the introduction of the third-party audit mechanism of medical insurance fund,and strengthen the ability construction of medical insurance team and medical staff,so as to improve the supervision level and effi ciency of medical insurance for high cost medical records.