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目的:优化医院医保管理流程,规范医生的医疗行为和患者的就医行为,从而减少医保拒付费用,保障医保基金的合理使用。方法:统计北京大学第一医院近2年门诊医保拒付数据,并进行描述性分析,加强医保拒付防控管理后,再对比门诊医保拒付数据的变化。结果:实施管控措施后,医保拒付减少,达到预期效果,城镇职工和居民医保的门诊次均费用、药占比也合理下降。结论:医保拒付涉及医院管理、医疗和患者等多方面原因,医院医保管理部门应充分利用信息化技术,优化管理流程,精细化管理环节,动态跟进政策变化,不但能降低门诊医保拒付费用,还可以改善其他门诊医保控费指标。
Objective: To optimize the hospital medical insurance management process, standardize the doctor’s medical behavior and the patient’s medical treatment, so as to reduce the medical insurance protest fee and ensure the rational use of the medical insurance fund. Methods: Statistics Peking University First Hospital in the past two years, outpatient medical insurance pay data, and descriptive analysis, strengthen medical insurance prevention and control management, and then compare the changes in outpatient medical insurance. Results: After the implementation of control measures, medical insurance declined to achieve the expected results, the average cost of out-patient medical insurance for urban workers and residents, the proportion of medicine also decreased reasonably. Conclusion: The medical insurance protections involve many reasons, such as hospital management, medical treatment and patients. The hospital medical insurance management department should make full use of information technology, optimize the management process, refine management and follow up the policy changes dynamically, which will not only reduce out-patient medical insurance protest Costs, but also can improve other out-patient Medicare control indicators.