医疗服务收费智能监控政策梳理、方案比较与启示

Policy Sorting,Scheme Comparison,and Enlightenment for Intelligent Monitoring of Medical Service Charging

医疗服务收费场景既多又复杂,为适应医保飞行检查全覆盖新形势,将价格管理风险控制点嵌入临床相关业务流程,对收费流程各环节进行智能审核是提高价格管理效能、确保医疗收入合规的迫切要求。本文在对国家层面医疗服务收费智能监控政策梳理基础上,对典型地区医疗服务收费智能监控实施方案进行了比较。典型地区经验为公立医院开展医疗服务收费智能监控带来了以下启示:推进医疗收费智能监控规则库建设,扩大监控范围,实现智能审核全覆盖;引进医疗收费智能审核系统,将审核规则内置于业务流程,控制不合理收费。

The charging scenarios for medical services are both numerous and complex.To adapt to the new situation of full coverage of medical insurance flight inspections,embedding price management risk control points into clinical related business processes and conducting intelligent audits of all aspects of the charging process is an urgent requirement to improve the efficiency of price management and ensure compliance with medical income.On the basis of sorting out the intelligent monitoring policies for medical service fees at the national level,this article compares the implementation plans for intelligent monitoring of medical service fees in typical regions.The experience of typical regions has brought the following enlightenment for public hospitals to carry out intelligent monitoring of medical service fees:promoting the construction of intelligent monitoring rule banks for medical fees,expanding the monitoring scope,and achieving full coverage of intelligent audits;introducing an intelligent review system for medical fees,and incorporating review rules into business processes to control unreasonable fees.