基于故障树分析的医保基金使用风险识别与防控实践

Risk identification and prevention and control for medical insurance fund utilization based on fault tree analysis

强化医保基金监管是促进医疗保障制度健康持续发展的重要举措。2022年1月,北京某三甲综合医院开展了医保基金使用风险识别与防控实践,通过运用故障树分析和风险矩阵等方法,量化评估事件发生可能性和金额影响度,识别医保基金使用过程中的高风险事件,并制定相应的风险防控措施,依托智能化监管系统进行防控。2022年1—11月由超药品说明书适应证、超医保适应证和超年龄限制高风险事件造成的医院门诊医保拒付金额(20080元)较2021年同期(11585元)下降了42.30%,医保患者出院结账时间从3个工作日降至1个工作日。该实践有效提升了医院医保基金的监管质量和效率,改善了患者就医体验,为加强医疗机构安全规范使用医保基金提供参考。

Strengthening the supervision of medical insurance funds is an important measure to promote the healthy and sustainable development of the medical security system.In January 2022,a tertiary general hospital in Beijing carried out risk identification and prevention and control practices for the use of medical insurance funds.By using such methods as fault tree analysis and risk matrix,the probability and impact of events were quantitatively evaluated,high-risk events during the use of medical insurance funds were identified,and corresponding risk prevention and control measures were developed,relying on intelligent regulatory systems.From January to November 2022,the hospital outpatient medical insurance refusal amount(20080 yuan)caused by such high-risk events as exceeding drug instructions,exceeding medical insurance indications,and exceeding age limits decreased by 42.30% compared to the same period in 2021(11585 yuan).The discharge and settlement time of medical insurance patients decreased from 3 working days to 1 working day.This practice had effectively improved the quality and efficiency of hospital medical insurance fund supervision,improved patients'medical experience,and provided reference for strengthening the safe and standardized use of medical insurance funds by medical institutions.