广州市大型公立医院医保智能监控体系的构建与提升策略研究

Research on the construction and improvement strategies of the intelligent medical insurance monitoring system in large public hospitals in Guangzhou city

随着医疗保障体系的持续发展和完善,对医保管理提出了更高的标准化和效率要求。选取广州市一所著名的双一流大学附属医院作为案例,探讨了医保智能监控体系的构建和提升策略。首先,从国家、政策和机构层面进行了分析,强调了构建医疗保险智能监控体系的迫切性和必要性。接着,对当前国内外研究现状进行了全面回顾,突出了国内智能审计系统在智能水平、医院级智能监控的复杂性以及规则库标准化方面面临的挑战。之后,详细介绍了广州市公立医院在医保智能监控体系上的实践,包括体系构成、组织工作模式和规则库标准化建设。最后,总结了这些实践对医疗服务行为规范和医保质量管理效率提升的积极影响,并提出了未来研究方向的见解。

With the continuous evolution and refinement of the healthcare insurance system,there arises a heightened demand for the standardization and efficacy of healthcare insurance management.This paper takes a prominent public hospital in Guangzhou City as a case study to delve into the establishment and enhancement of an intelligent monitoring system for healthcare insurance.Initially,an analysis is conducted from the perspectives of the national,policy,and institutional levels to underscore the imperative and urgency of constructing an intelligent monitoring system for healthcare insurance.Subsequently,a comprehensive review of the current research landscape,both domestically and internationally,is presented,highlighting the challenges faced by domestic intelligent auditing systems in terms of their level of intelligence,the sophistication of hospital-level intelligent monitoring,and the standardization of rule libraries.Following this,the paper elaborates on the practical endeavors undertaken by large public hospitals in Guangzhou City regarding the construction and optimization of the intelligent monitoring system for healthcare insurance.This encompasses aspects such as the structure of the intelligent monitoring system,collaborative management in operational modes,and the standardization of rule libraries.Finally,the paper concludes by summarizing the positive impact of these practices on the regulation of medical service behaviors and the enhancement of efficiency in healthcare insurance quality management,while also offering insights into future research directions.