[1]吴菁菡,王 博,张 驰,等.医保智能审核系统用于限定支付医保用药管控的效果评价[J].医学信息,2025,38(21):65-68.[doi:10.3969/j.issn.1006-1959.2025.21.012]
 WU Jinghan,WANG Bo,ZHANG Chi,et al.Effect Evaluation of Medical Insurance Intelligent Audit System in Controlof Restricted-payment Medical Insurance Drugs[J].Journal of Medical Information,2025,38(21):65-68.[doi:10.3969/j.issn.1006-1959.2025.21.012]
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医保智能审核系统用于限定支付医保用药管控的效果评价()

医学信息[ISSN:1006-1959/CN:61-1278/R]

卷:
38卷
期数:
2025年21期
页码:
65-68
栏目:
卫生管理信息学
出版日期:
2025-11-01

文章信息/Info

Title:
Effect Evaluation of Medical Insurance Intelligent Audit System in Controlof Restricted-payment Medical Insurance Drugs
文章编号:
1006-1959(2025)21-0065-04
作者:
吴菁菡王 博张 驰孙 阳王晨歌刘学才
郑州大学第一附属医院医疗保险管理办公室,河南 郑州 450000
Author(s):
WU Jinghan WANG Bo ZHANG Chi SUN Yang WANG Chenge LIU Xuecai
Medical Insurance Management Office, the First Affiliated Hospital of Zhengzhou University, Zhengzhou 450000, Henan, China
关键词:
医保用药智能审核系统限定支付医保用药医保用药处方
Keywords:
Medical insurance intelligent audit system Restricted-payment medical insurance drugs Medication prescription for medical insurance
分类号:
R197
DOI:
10.3969/j.issn.1006-1959.2025.21.012
文献标志码:
A
摘要:
目的 分析医保智能审核系统用于限定支付医保用药的管控效果。方法 分析2022版、2023版《国家基本医疗保险、工伤保险和生育保险药品目录》中限定支付药品的备注和说明书等资料,构建我院医保用药智能审核系统,于2023年7月19日起上线使用,从医保用药智能审核系统运行前(2023年6月1日-30日)、运行后(2024年1月1日-31日)的医保用药处方中各随机抽选500张,将运行前纳入处方设为对照组,运行后纳入处方设为研究组。比较两组中各类型拒付的数量与金额情况。结果 研究组的限工伤生育保险、限适应证、限特殊人群(包含新生儿、儿童)、限定性别的拒付数量、拒付金额均明显下降,且低于对照组(P<0.05)。结论 使用医保用药智能审核系统可降低医保拒付风险发生率,提升医院医保管理的管控效果。
Abstract:
Objective To analyze the control effect of medical insurance intelligent audit system in control of restricted-payment medical insurance drugs. Methods Through the analysis of the notes and instructions of the restricted-payment drugs in the 2022 edition and 2023 edition of National Drug List for Basic Medical Insurance, Work Injury Insurance, and Maternity Insurance, the intelligent audit system of medical insurance drugs in our hospital was constructed. It was put into use on July 19, 2023. Before the operation of the intelligent audit system of medical insurance drugs (from June 1, 2023 to June 30, 2023) and after the operation (from January 1, 2024 to January 31, 2024), 500 prescriptions were randomly selected, and the prescriptions before the operation were set as the control group. After operation, the included prescriptions were set as the study group. The number and amount of various types of refusals in the two groups were compared. Results The study group demonstrated a significant decrease in both the frequency and total amount of payment denials across all categories, including restrictions for work-injury and maternity insurance, specific indications, special populations (encompassing neonates and children), and patient gender, and were lower than those in the control group (P<0.05). Conclusion The use of medical insurance drug intelligent audit system can reduce the payment denials and enhance the effectiveness of hospital medical insurance management.

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更新日期/Last Update: 1900-01-01