DIP支付背景下医保结算清单管理的探索与实践

Exploration and Practice of Medical Insurance Settlement List Management in the Context of DIP Payment

目的探索提升医保结算清单数据质量的方法,减少因数据质量问题导致的付费损失。方法在技术上,实施诊断组录入平台、手术操作自动同步和排序功能,辅助决策系统、病案首页校验功能,局端数据和院端数据校验功能;在管理上,建立病案首页数据审核机制、医保结算清单预先审核机制。结果医保结算清单首次上传成功率上升了50.17个百分点,首页缺陷率下降了80.44个百分点,全院综合病例组合指数(CMI)值提升了0.13。结论利用信息技术和建立审核机制是提升医保结算清单管理水平的重要措施。

Objective To explore methods for improving the data quality of medical insurance settlement lists and reducing payment losses caused by data quality issues.Methods Technologically,a diagnostic group entry platform,automatic synchronization and sorting functions for surgical operations,a decision support system,a verification function for the cover page of medical records,and validation functions for both central and hospital data were implemented.Managerially,a data review mechanism for the cover page of medical records and a pre-review mechanism for medical insurance settlement lists were established.Results The success rate of the first upload of medical insurance settlement lists increased by 50.17 percentage points,the defect rate of cover pages decreased by 80.44 percentage points,and the hospital's overall Case Mix Index(CMI)value increased by 0.13.Conclusion Utilizing information technology and establishing review mechanisms are important measures for improving the management level of medical insurance settlement lists.