医保合理收费审计系统的设计与应用

Design and Application of Medical Insurance Reasonable Charge Audit System

目的建立覆盖事前提醒、事中质控、事后监管的全过程医保基金闭环管理体系,保证医保基金使用的合理性,提升医院精细化管理水平。方法根据制度、法规全面梳理审计规则,建立审计知识库,利用“医保管理+大数据”智能化平台,通过住院医嘱违规提醒、在院患者每日审计、患者转科/出院审计拦截、门诊病历违规提醒等多种审计方式在患者就诊期间进行动态审计,对历史数据进行大数据审计和医保指标分析,定位医保管理薄弱环节,构建全方位、全流程医保基金智能管理体系。结果应用医保合理收费审计系统后,我院患者药占比(27.41%±3.38%vs.29.39%±2.87%)、耗占比(18.00%±1.60%vs.21.38%±2.00%)、辅助用药收入占比(0.33%±0.26%vs.0.43%±0.29%)、抗菌药物使用率(34.93±0.83%vs.40.43%±2.84%)、抗菌药物使用强度(37.13%±3.21%vs.40.43%±2.84%)、门诊患者次均费用[(150.03±6.73)元vs.(180.25±5.95)元]相较于应用前显著下降,且差异有统计学意义(P<0.05);基本用药收入占比较应用前升高(31.69%±2.74%vs.30.49%±3.57%,P=0.030);出院患者次均费用较应用前有所下降[(17607.20±8060.41)元vs.(20942.33±9991.38)元],但差异无统计学意义(P=0.050)。结论基于“医保管理+大数据”的合理收费审计系统,提升了医保基金监控效率,实现了医保精细化、动态化、现代化管理变革。

Objective To establish a closed-loop management system of medical insurance fund covering the whole process of prereminder,in-process quality control and post-supervision,so as to ensure the rational use of medical insurance fund and improve the level of the hospital’s delicacy management.Methods The audit rules were comprehensively sorted out according to the system and regulations,the audit knowledge base was established.And the intelligent platform of“medical insurance management+big data”was used to conduct dynamic audit during the treatment period of patients through a variety of audit methods,such as reminding of medical orders’violations,daily audit of in-hospital patients,interception of patient transfer/discharge audit,reminding of outpatient medical records’violations.And the big data audit and medical insurance indicators analysis on historical data was conducted,the weak links in medical insurance management was located,and then an all-round and whole process intelligent management system for medical insurance funds was built.Results After applying the medical insurance reasonable charge audit system,in our hospital,the proportion of drugs(27.41%±3.38%vs.29.39%±2.87%),the proportion of medical consumables(18.00%±1.60%vs.21.38%±2.00%),the proportion of income from adjuvant drugs(0.33%±0.26%vs.0.43%±0.29%),the usage rate of antibiotics(34.93%±0.83%vs.40.43%±2.84%),the usage intensity of antibiotic(37.13%±3.21%vs.40.43%±2.84%),and the average cost per outpatient visit[(150.03±6.73)yuan vs.(180.25±5.95)yuan]were significantly decreased compared with before application,and the difference was statistically significant(P<0.05).The proportion of income from essential drugs was higher than before(31.69%±2.74%vs.30.49%±3.57%,P=0.030).The average cost of per discharged patients was decreased[(17607.20±8060.41)yuan vs.(20942.33±9991.38)yuan],but the difference was not statistically significant(P=0.050).Conclusion The reasonable charge audit system based on“medical insurance management+big data”has improved the monitoring efficiency of medical insurance fund and realized the delicacy,dynamic and modern management reform of medical insurance.