基于前置审方系统的医保用药智能审核系统构建及应用

Construction and application of an intelligent insurance medication audit system based on pre-auditor system

构建医院医保用药智能审核系统,对规范不合理用药行为、控制医保费用不合理增长有重要意义。某三级甲等医院通过分析医保合理用药要求,分别在适应证、营养风险筛查、疼痛程度评分、药敏试验结果、适用人群等方面制定处方审核规则,当使用医保基金结算时进行系统和人工双重审核,并根据处方问题予以"提示、审核、拦截"三级干预处置措施。系统启用后,医院的事中信息系统监管模式从既往的以提示为主转向以审核为主,医保智能审核系统进行及时提示与干预,医院的事后点评医保不合理处方数、医保抽检处方扣减数明显下降(P<0.001),医保用药处方审核数量提升(P<0.001)。医保用药智能审核系统的应用,提高了处方审核效率,保障了医保基金使用合理性。

The establishment of an intelligent audit system for hospital medical insurance is crucial for standardizing irrational practices and curbing the unwarranted escalation of medical insurance costs.A tertiary hospital has developed comprehensive prescription review rules in terms of indications,nutritional risk assessments,pain score evaluations,drug sensitivity test results,and target patient populations.When using medical insurance funds for settlement,both systematic and manual reviews are conducted,and three-level intervention measures such as"prompt,review,and interception"are implemented based on prescription issues.After the system was put into use,the hospital′s in-process information system supervision mode shifted from the previous focus on prompts to focus on audits.The medical insurance intelligent audit system provided timely prompts and interventions,and the number of unreasonable medical insurance prescriptions and deductions from medical insurance sampling prescriptions significantly decreased(P<0.001),while the number of medical insurance medication prescription audits increased(P<0.001).The application of the intelligent medical insurance medication audit system has improved the efficiency of prescription auditing and ensured the rationality of the use of medical insurance funds.