基于失效模式与效应分析的医保信息化监管体系建设

Construction of medical insurance informatization supervision system based on failure mode and effect analysis

各类检查和自查发现,医院在诊疗及收费中的合规性及合理性问题较为常见,多次出现医保拒付情况。某院应用失效模式与效应分析,梳理诊疗和收费流程中的高风险点,构建6大信息化改造场景并制定具体改造措施,提前规避或减少医保拒付的出现。通过医保监管数字化改造,实现了事前审核、事中提醒及智能修正、事后大数据精准分析的全流程智能监管,促进了医务人员合规诊疗及精准收费,可为其他医疗机构合理使用医保基金提供参考。

In various types of inspections and self-inspections,it was found that compliance and rationalization in diagnosis and charging were the more common problems in hospital,leading to refusal of medical insurance payment.In 2022,the failure mode and effect analysis was conducted in a Grade-A tertiary hospital in Jinhua to identify the high-risk points in the process of diagnosis and treatment and charging,and building six major information technology transformation scenarios and formulating specific transformation measures,to avoid or reduce the refusal of medical insurance payment in advance.Through the digital transformation of medical insurance supervision system,a whole process intelligent supervision has been implemented,including pre event review,mid event reminder and intelligent correction,and post event big data precise analysis.It promoted compliant diagnosis and treatment of medical personnel and accurate charging,which could provide reference for other medical institutions to use medical insurance funds reasonably.