摘要
DRG支付方式下的高靠分组是指服务提供方故意系统地改变报告的病例组合,以获得更多医保付费的行为,会给医保基金安全带来风险。2021年国家医疗保障局提出未来三年实现基于DRG/DIP支付方式的统筹地区、医疗机构、病种分组、医保基金四个方面全面覆盖,高靠分组作为最具破坏性的行为,应作为监管方的稽核重点。传统的人工审核方法效率不足,国际经验均指向计算机辅助智能审核的综合监管模式。本文回顾相关文献,系统梳理发达国家应对DRG高靠分组的方法与发展历程,结合我国DRG试点与进展现状,提出发展智能审核手段,高效应对DRG高靠分组的路径与建议。
“Up-coding” under the diagnosis-related group payment refers to the behavior that providers deliberately and systematically change the reported case mix in order to obtain more medical insurance payment,which brings risks to the security of medical insurance funds. In 2021, the National Healthcare Security Administration proposed to achieve full coverage of regions, medical institutions, disease groups and medical insurance funds based on DRG/DIP payments in the next three years. As the most destructive behavior, upcoding should be the focus of supervision. The traditional manual auditing method is inefficient, and international experience prefers the comprehensive supervision mode of computer-aided intelligent auditing. This paper systematically summarizes the methods and development of dealing with DRG up-coding, and proposes paths and suggestions to develop intelligent audit means in dealing with DRG up-coding in China.
出处
《中国医疗保险》
2022年第6期44-47,共4页
China Health Insurance
