基于无监督算法的DRG细分组在编码高套上的应用研究

Application of Unsupervised Algorithm in DRGs Subdivision Group on High Bit Rate Coding

2021年9月29日,国务院办公厅《关于印发“十四五”全民医疗保障规划的通知》中要求积极探索将按疾病诊断相关分组付费等新型支付方式。这种支付方式,对医保基金的监管提出了新的挑战。文章将探索在DRG支付方式下,通过无监督算法,挖掘在同一核心组下,治疗方式不同对于不同细分组所产生的规则,跟原来通过不同辅助诊断进入不同细分组形成相对应关系,从而对细分组中通过辅助诊断中的编码升级进入更高一级的分组进行监控,及时发现可疑骗保行为,通过事前提醒、事后监管减少医保基金的流失。

On September 29,2021,the General Office of the State Council issued the Notice on Printing and Distributing the"Fourteenth Five Year Plan"Medical Security Plan for All,which requires active exploration of new payment methods such as payment by disease diagnosis related groups.This payment method poses new challenges to the supervision of medical insurance funds.This paper will explore the DRG payment method,through unsupervised algorithms,to discover the rules generated different treatment methods for different sub groups under the same core group,forming a corresponding relationship with the original sub groups entered through different auxiliary diagnosis,so as to monitor the sub groups entered into a higher level through the code upgrade in the auxiliary diagnosis,timely find suspicious fraud Post supervision reduces the loss of medical insurance funds.