DRG/DIP付费下医疗机构违规行为的认定依据及处理模式研究

Research on the Identification Basis and Treatment Mode for the Violation Behavior of Medical Institutions Under DRG/DIP Payment

随着DRG/DIP支付方式改革的不断推进,DRG/DIP付费下新出现的高靠编码等违规使用医保基金行为逐渐突显,而这些行为在《医疗保障基金使用监督管理条例》(以下简称《条例》)中尚无完全对应的表述和定义。这些违规行为依何处理、如何处理、怎样定损在全国范围内尚无科学、统一、可操作的实践标准。基于上述背景,本文分析了DRG/DIP付费下医疗机构违规行为认定及处理过程中存在的问题,阐述了DRG/DIP付费下医疗机构违规行为与《条例》中具体条目的一一对应关系,探讨了DRG/DIP付费下医保基金的定损方式,为进一步提高医保部门的行政执法能力及医保基金精细化管理水平提供理论依据。

With the continuous promotion of DRG/DIP payment reform,the newly emerged illegal use of medical insurance fund such as upcoding is becoming more prominent,and there is no corresponding expression and definition of these behaviors in The Regulations on the Supervision and Administration of the Use of Healthcare Security Funds(hereinafter referred to as The Regulations).There is no scientific,unified,and operable practical standard nationwide on the basis,solution,and loss assessment of these violations.Therefore,this paper focuses on the issues existed in identification and treatment of hospitals’violations under DRG/DIP payment,explains the one-to-one correspondence among the violations and the specific items in The Regulations,and discusses the accurate way to determine the damage to the healthcare security fund under DRG/DIP payment,which provides theoretical basis for further improving the administrative law enforcement ability of the healthcare security department and the refined management of the healthcare security fund.