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目的通过分析医院门诊内科医保拒付情况,为降低医保拒付和促进合理治疗提供参考依据。方法统计某医院2012年~2014年门诊内科系统各科室医保拒付数据,对医保拒付情况进行描述性分析。结果在2012年到2014年间,某医院门诊内科系统共发生医保拒付4854例,拒付费用达15.9万元,其中心脏中心就诊人次数最多,产生医保拒付次数最多,为2226例,拒付金额为45214元。拒付原因以累计开药超量和单次开药超量为主,分别占总次数的80%和15%。结论通过分析医院门诊内科医保拒付情况,可以及时制定医保管理制度和多部门动态对接医保政策等改进措施,可有效降低医保拒付现象的发生。
Objective To analyze the hospital outpatient medical insurance refusal to pay, to provide a reference for reducing medical insurance refunds and promoting rational treatment. Methods Statistics of medical insurance refusal data of various departments of outpatient internal medicine system in a hospital from 2012 to 2014, and descriptive analysis of medical insurance refusal. Results Between 2012 and 2014, a total of 4,854 medical insurance refusals occurred in a hospital outpatient internal medicine system, with the cost of refusing payment up to 159,000 yuan. Among them, the number of visits to the heart center was the largest, with the highest number of medical insurance refusals, accounting for 2226 cases, The amount of 45,214 yuan. The reasons for the refusal to pay the total amount of overdose and single prescription overdose, respectively, accounting for 80% and 15% of the total number. Conclusion By analyzing the outpatient medical insurance refusal situation, we can make timely medical insurance management system and multi-sector dynamic docking health insurance policies and other improvements, which can effectively reduce the occurrence of medical insurance refusal.