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目的对某医院的医疗项目审核扣款进行归类分析,针对医院医疗项目审核扣款提出管理对策建议。方法对成都市某三级甲等医院2013年6月-12月的项目审核扣款按原因进行归类并分析扣款的根本原因。结果某医院2013年6月-12月的总扣款项目为30 000余条,涉及金额约300万元,重复收费、超量收费、不合理收费、挂靠收费、收费与医嘱不一致、无适应证、超比例收费和超限制收费的项目数占比分别为42.99%、39.71%、9.15%、5.73%、0.35%、0.17%、1.44%和0.46%,其金额占比分别为8.84%、52.55%、14.44%、10.70%、2.54%、1.15%、8.91%和0.88%。结论项目审核扣款原因错综复杂,医院可针对原因分析结果,通过加强信息化建设、物价管理和与医疗保险管理机构、物价局建立有效的沟通谈判机制等方式,使医疗保险扣款降低、患者的权益得到保障,以及提升医疗保险基金使用效率,使医保患三方受益。
Objective To classify and analyze the deductions of medical projects in a hospital and propose management countermeasures for the deductions of hospital medical projects. Methods The project audit deductions of a Grade A hospital in Chengdu from June to December in 2013 were categorized according to the causes and the root causes of the deductions were analyzed. Results In June 2013 to December 2013, a total of 30,000 items were deducted from a hospital, involving an amount of about 3 million yuan. Repeated charges, excessive charges, unreasonable charges, unreasonable charges, inconsistent fees and medical orders, no indications , Accounting for 42.99%, 39.71%, 9.15%, 5.73%, 0.35%, 0.17%, 1.44% and 0.46% of the total respectively, accounting for 8.84% and 52.55% of the total respectively, , 14.44%, 10.70%, 2.54%, 1.15%, 8.91% and 0.88% respectively. Conclusion The causes of project chargeback are complicated. The hospital may, according to the result of the analysis, lower the medical insurance charge by strengthening information construction, price management and establishing an effective communication and negotiation mechanism with the medical insurance administration and the Price Bureau. The patients’ Rights and interests are protected, as well as improve the efficiency of the use of medical insurance funds, Medicare benefit tripartite benefit.