Change passive management is the source governance, and the use of public hospital medical insurance funds is more standardized

With the "Guidelines for the Reform of the State Council's General Office on Promoting the Reform of the Supervision Fund Supervision System" (Guoqi Fa [2020] No. 20) and the "Regulations on the Supervision and Administration of Medical Security Fund" (hereinafter referred to as the "Regulations") The promulgation of national regulations, the system of supervision of the medical insurance fund supervision is gradually improved, the Regulations have stipulated the content, form, form and responsibilities, obligations, and rights of medical institutions in the use of the fund's use. Task and institutional guarantee, to medical institutions clearly show the red line of unspeakable medical security funds that cannot be touched, for medical institutions to standardize medical services price charges, reasonable diagnosis and medication, ensure the direction of medical security funds, the supervision work of medical security funds, the more Let's present the situation of legalization, standardization, and professionalization.

Strengthen the internal supervision of hospitals, use medical insurance funds safely and reasonably, are related to national policies, mass interests, and have a good reputation and public welfare image of public hospitals. The three -party win -win goal of diagnosis and treatment behavior is more standardized and patients with high -quality medical services.

The problems and reasons for the management of medical insurance funds

In recent years, the National Medical Insurance Bureau has continued to carry out special governance of cracking down fraud and fraudulent medical security funds. In 2020, 620,000 designated medical institutions were inspected, and more than 390,000 medical institutions that violated laws, violations, and breach of contract were recovered. 100 million yuan. The Provincial and Municipal Medical Insurance Bureau simultaneously implemented the "Special Governance of the Medical Insurance Fund" and "Clear Action of Historical Issues". Through medical institutions, comprehensively investigated and rectified, medical insurance, and health and health departments comprehensively inspected illegal charges and other illegal historical stocks question. After inspection, it was found that the hospital has risk points such as super -standard charges, repeated charges, restructuring project charges, super -medical insurance limited payment scope, unreasonable hospitalization, unreasonable diagnosis and treatment, and other risk points. Pay and punish. After in -depth discussions and analysis, the medical insurance and price management departments of a three -level hospital in Taizhou City have summarized the causes of violations as follows.

1. Insufficient functions of hospital price management departments

The price of medical service items, drug prices, and medical consumables in the hospital belong to the three offices of the Price Section, the Department of Pharmacy, and the Medical Consumption Management Office. Each department is managed within the function of the office. Interoperability and formation of unified regulatory mechanisms, the implementation effect of the charging policy is lacking, and the functions of functions need to be improved.

2. The degree of paid attention to clinical medical staff is not enough

Individual medical staff understands the medical insurance policy and price policy one aspect. It is believed that as long as the patient needs to do related examinations and treatment for the patient, the corresponding fees should be charged, thereby ignoring the medical insurance and price policy specifications, such as "oxygen inhalation", "wound negative surface negative surface" "Pressive treatment" daily charging amount is at the highest price, not charging fees according to the actual treatment period; individual medical staff lacks a sense of responsibility, the medical order, report form (or record form), and the charging list are not in line, which makes the charges lack reasonable and sufficient in accordance with.

3. The fees of some medical projects are unclear, and there is a deviation in the policy understanding

At present, the hospital's "Jiangsu Provincial Medical Service Price Manual" (hereinafter referred to as the "Handbook") is a revised version in 2010. On the basis of this version, it is dynamically updated and maintained according to the provincial price management department price adjustment document. The "Handbook" traditional Chinese medicine service project has a total of more than 5,000 items. Some projects, the connotation of the pricing unit, the except content and the description of the description are blurred, and the charging standards cannot be accurately defined. There are different degrees of deviations between departments and medical institutions' understanding of the charging policy. For example, the "air pressure treatment" price unit is "each part", and the medical insurance regulatory department believes that a limb is a part, which is inconsistent with the understanding of the medical institution, causing the non -subjective violations of medical institutions.

4. Unable to use the information system monitoring method

Hospital information has become a technical support for the development of hospitals. In the implementation of medical insurance and price policies, there are countless risk control points. Intelligent monitoring and screening are particularly important for the supervision of medical insurance funds. At this stage, the hospital's medical insurance and price management have been basically improved afterwards, but there are still certain defects in the reminder and control in the past. The hospital is a comprehensive hospital. As a result, the amount of violations is huge, and it is imperative to effectively use the support function of informatization in the supervision of hospital medical insurance funds.

5. The functional department fund supervision and assessment is not enough

When the hospital's functional departments conduct an illegal use of the medical insurance fund verification, the rectification measures within a time limit cannot keep up, the inspection depth is not enough, and the irregular behavior of the clinical department is mainly based on training, reminding, criticism. The medical insurance fund uses the long -term mechanism of internal supervision.

Medical Insurance Fund Used Internal Supervision Measures

1. Improve the organization, improve the price management system, and strengthen the supervision mechanism

In accordance with the requirements of the "Internal Price Behavior Management Regulations" issued by the National Health and Health Commission, combine the actual situation of the hospital to improve and adjust the basic structure of the price management committee. The price management committee has a management office, which uses part -time prices as a direct executor of the price policy and the end of the price management. The hospital has adjusted the functional departments in the functional departments to merge the function of the price department to the Medical Insurance Office. Form the price management system jointly regulated by medical insurance, finance, nursing, medical, pharmacy, consumables, equipment, information, auditing, quality control, and disciplinary inspection, so as to restrict each other, cooperate with each other, clear responsibilities, and interoperability. 2. Special training and guidance for medical insurance and price policy for in -depth clinical specialists

In order to strengthen the understanding of medical insurance and price policies, to increase their sense of responsibility and legal system, and avoid the deviation of policy understanding, the Hospital Medical Insurance Office deepened 31 specialists to interpret the "Regulations on the Supervision and Management of Medical Security Fund". The contents of the negative list documents issued by the Provincial and Municipal Medical Insurance Bureau, the problems found in the inspection of the higher -level price supervision department, and the illegal behavior of the hospital's conventional charging inspection work, conduct targeted training and guidance, and the charging items involved in various colleges involved Connotation, explanation to explain one by one, promote clinical medical staff to comply with clinical technical specifications, various operational specifications and medical ethics specifications, reasonable diagnosis and treatment, and treat them due to illness; The national, provincial, and municipal regulations on the supervision of price and medical insurance funds compiled the "Taizhou People's Hospital Price Management Manual" (first edition) to the department to facilitate the accurately grasped price charging policy of the clinical department and standardize and reasonable charges.

3. Invite professional inspectors to come to the hospital to guide the charges

The hospital's medical insurance office invited the staff of the medical insurance fund regulatory department to have a flight inspection experience staff to the hospital to teach to conduct in -depth analysis and explanation of the key violations of the national medical insurance fund supervision policies and the discovery of the flight inspection, and actively request the inspector of the municipal medical insurance fund supervision department to the hospital Carry out simulated flight inspections, focusing on the decomposition charges, super -standard charges, repeated charges, unreasonable diagnosis and treatment and other behaviors, point out the hidden dangers of illegal charges in the hospital, jointly explore part of the doubtful charging content, help the hospital find problems, eliminate risks, block loopholes, and vulnerabilities, and vulnerabilities. Improve mechanism.

4. Standardize the source of the data and comprehensively sort out the HIS system toll library

The HIS system toll library of the hospital includes medical service projects, toll -available consumables, and group sets. The hospital's medical insurance office and consumables office jointly checked more than 20,000 charging consumable codes. According to the coding after approval, the proportion of reimbursement for the reimbursement of medical insurance will be re -prepared to ensure the standardization and accuracy of consumables. The Hospital Medical Insurance Office notified the clinical department to report to the undergraduate room "Toll Group Course and Project Bright Table". On the basis of facilitating clinical operations, the non -standard examination, diagnosis and treatment, and consumables are cleaned up in the group set; Whether the actual functions in the equipment use instructions are consistent, realize the same equipment (instrument) charging homogeneity management of the same hospital, and relative solidification of various specialty toll projects and consumables toll projects to avoid errors and errors; Product regulations must ensure that consumables are consistent with actual charges.

5. Effectively use informatization methods to promote the front of intelligent monitoring rules

Obtaining information system support, based on gender, age, charging quantity, charging amount, whether the scope of medical insurance payment is over limit, etc., establish intelligent monitoring rules, and strengthen the pre -reminder of standardized and reasonable use of medical insurance funds. Use big data comparison analysis to provide suspected illegal data reports that can be queried in real time, and automatically verify and early warning at the discharge, improve the supervision of the medical insurance fund supervision, and then build a comprehensive aspect of reminder, supervision in the event, and post -event review of the matter. , Full process, intelligent supervision system.

6. Implement the long -term mechanism of supervision and inspection and assessment in the use of medical insurance funds

The functional departments refer to the flight inspection model to carry out the rational use of self -examination and self -correction of the medical security fund, and regularly extract medical records in hospitals and discharged patients for verification. The hospital disciplinary inspection and supervision department and the performance accounting department fully participated in the supervision of the medical insurance fund, combined the monthly assessment with the year -end assessment, and did not meet the standards for the check rate of the discharge charging, the clinical departments with poor implementation and special inspection. Clarify illegal responsibilities, conduct monthly reports and deductions for monthly management, and implement accountability and punishment for departments that are seriously illegal and repeatedly taught. Formulate the "Medical Insurance Management, Medical Insurance Liaison Officer, Part -time Price Officer and Medical Insurance Physician Evaluation Plan" of the Taizhou People's Hospital, and include the content of medical insurance price policy training and transmission, the supervision of medical insurance funds, and the work of cooperating with medical insurance prices into the assessment. Details, according to the assessment rules, evaluate medical insurance liaison officers and part -time prices, and the assessment scores are used as the basis for performance management assessment. The "Administrative Measures for the Points of Medical Insurance Physicians in Taizhou People's Hospital" is issued, the medical insurance management responsibilities of practicing physicians are clear, and the points evaluation is implemented.

Effect and evaluation

By improving a series of improvement measures such as organizational organizations, specialized specialized training, standardized data sources, promoting intelligent monitoring, and implementation of reward and punishment systems, statistics before (July -December 2019) and improvement (July -December 2020 -December 2020 ) Illegal data, a total of 81791 articles were effectively recorded. The use of SPSS23.0 software to analyze the data to compare the number and amount before and after improvement. P <0.05 represents a statistical significance. After the improvement, the indicators such as the refusal of medical insurance have declined significantly (see Table 1), and the implementation of the improvement measures is obvious. Discussion and suggestions

1. Passive management into source governance

Under the current medical insurance management system, the sustainable operation of the medical insurance fund depends mainly on the internal supervision of the medical institution on its service behavior. External supervision has become an opportunity for the hospital to pay attention to and strengthen internal supervision. Reasonable, technical difficulty and risk technical services obtain compensation. Only the public hospital can strengthen the internal supervision mechanism of medical insurance, change the mind, move forward forward, and change the passive "urgent" and "fire extinguishing" management as the source governance, find the risk point in advance and guide the rectification, in order to fundamentally eliminate the medical security fund Illegal use.

2. Medical institutions should strengthen communication with the medical insurance regulatory department

Due to the large and complicated medical charges of public hospitals, in the case of inconsistent medical insurance or price policies, we must communicate with the medical insurance fund supervision department to obtain accurate and effective medical insurance and price policy information; for some prices and value Severe departure, unable to truly reflect the labor paid of medical staff, high costs that have a burden on hospital operations, and new technologies and new projects that enter clinical applications without charging standards. Newly increased and improved medical projects to declare, and for the hospital to strive for legal and compliant charging channels.

3. Establish a multi -party joint coordination mechanism, and strengthen policy communication between supervision departments at all levels

Under the high -pressure policy of strengthening the supervision of the National Medical Insurance Fund, public hospitals often face the medical security bureau, the market supervision and administration bureau, and the audit bureau to supervise. If the policy interpretation is not uniform, it will cause a certain problem to the policy implementation of the medical institution. I hope that the municipal -level regulatory authorities, between provincial and municipal regulatory departments will strengthen policy standard communication. Improve the "Prices of Jiangsu Medical Service Projects" to effectively solve the difficulties of medical insurance fund management of medical institutions; for disputes caused by the unclear charging connotation and standards, it is recommended to establish an effective multi -party joint coordination mechanism to solve disputes in a timely and effectively.

4. Value mining, optimize income structure

Hospital medical insurance and price management are managed from extensive cost control to refined expenses. While eliminating unreasonable charges, the hospital reflects the technical and labor value of medical personnel by digging and applying for new technologies and new projects. At the same time, DRG/DIP payment increases increase Policy support for new technologies and new projects, return service prices to the value of medical affairs itself, and optimize the hospital's income structure. This is not only a problem that the hospital's DRG/DIP payment method reform needs to be considered. It is also the direction of high -quality development and public hospital reform of hospitals. And requirements.

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