基于医保全程审核系统的设计与应用

Design and Application of Intelligent Audit System Based on Whole-Process of Medical Insurance

目的最大限度避免医保违规,保障患者顺利实现医保结算,解决传统审核系统无法满足医院对患者全部诊疗救治过程监管的问题。方法系统采用面向对象方法,利用Java编程语言和Oracle数据库,实现对患者入院后的医疗活动(如病案首页、住院病历、检验检查报告单、体温单、长期和临时医嘱、费用等)进行全过程审核、定时审核、出院审核等,并探讨系统的应用成效。结果系统上线后,不合理的诊疗行为可以及时反馈给医护人员,实现对患者门诊、住院所有诊疗活动的审核。疑似违规次数由系统上线前的(9.10±0.23)万条下降至(3.30±0.08)万条,拒付金额由(982.00±3.16)万元下降至(351.00±1.69)万元,每份病历平均审核时间从(10.30±0.12)min缩短至(3.20±0.11)min,患者满意度从96.20%±0.12%提升至98.60%±0.10%,且差异均有统计学意义(P<0.001)。结论医保全程审核系统对于规范诊疗行为、优化审核流程、推动医保工作的精细化管理,有着十分重要的意义,值得推广应用。

Objective To maximize the avoidance of medical insurance violations,ensure the smooth implementation of medical insurance settlement for patients,and to solve the problem of traditional audit systems not being able to meet the supervision of all patient diagnosis and treatment processes in hospitals.Methods The system adopted object-oriented method,Java programming language and Oracle database to realize the whole-process audit,regular audit and discharge audit of the medical activities of patients after admission(such as the first page of medical records,inpatient records,inspection reports,temperature sheets,long-term and temporary medical orders,expenses,etc.).And the application effectiveness of the system was discussed.Results After launch of the system,unreasonable diagnosis and treatment behaviors could be timely fed back to medical personnel to realize the audit of all diagnosis and treatment activities in the outpatient and inpatient departments.The number of suspected violations decreased from(91.0±2.3)thousand before the system launched to(33.0±0.8)thousand,and the amount of non-payment decreased from(9820.0±31.6)thousand yuan to(3510.0±16.9)thousand yuan.The average review time of each medical record was shortened from(10.30±0.12)min to(3.20±0.11)min,and patient satisfaction was increased from 96.20%±0.12%to 98.60%±0.10%,with statistical significance(P<0.001).Conclusion The whole-process medical insurance audit system is of great significance for standardizing the diagnosis and treatment behavior,optimizing the audit process,and promoting the fine management of medical insurance work,and it is worth promoting and applying.