| 引用本文: | | 吴德凯,崔玉洁,潘 钰,尹露露,张洪成*.[cn_title][J].[journal_cn_name],2023,[volume]([issue]):1585-1589.[点击复制] |
| | WU Dekai,CUI Yujie,PAN Yu,YIN Lulu,ZHANG Hongchen*.[en_title][J].[journal_en_name],2023,[volume]([issue]):1585-1589.[点击复制] |
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| 摘要: |
| 目的：分析徐州市DRG-PPS智能监管平台数据，为基于医保基金大数据智能监管DRG支付提供参考依据。方法：对2022年4-12月徐州市六家三级医院触发的DRG监管规则进行整理，分析徐州市DRG监管规则触发点及规则内涵。结果：收费问题是基金监管的重点，首批上线的监管规则覆盖病种较少，恶性肿瘤相关诊断的病例是触发规则最多的病种，病案首页质量需要进一步提高。结论：智能监管可使医疗行为更加规范，医院、医保应协同管理，共同维护医保基金安全。 |
| 关键词: 医保基金 疾病诊断相关分组 医保监管 智能监管 |
| DOI： |
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| 基金项目:江苏省医院协会重大课题（JSYGY-2019-517） |
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| Analysis on the Effectiveness of Intelligent Supervision of Medical Insurance Funds under DRG Payment Method△ |
| WU Dekai,CUI Yujie,PAN Yu,YIN Lulu,ZHANG Hongchen* |
| (Medical Insurance Management Office，The Affiliated Hospital of Xuzhou Medical University) |
| Abstract: |
| Objective：To provide theoretical basis and practical reference for intelligent supervision of DRG payment based on big data through the introduction of Xuzhou DRG-PPS supervision mode and data analysis of intelligent supervision platform. Methods：The DRG regulatory rules triggered by six tertiary hospitals in Xuzhou City from April to December 2022 were sorted out，and the trigger points and connotation of the DRG regulatory rules in Xuzhou city were analyzed. Results：Through the research，it was found that the charge issue was still the focus of fund supervision，the first batch of online regulatory rules covered fewer diseases，and the cases related to malignant tumor diagnosis were the diseases triggering the most rules，and the quality of the first page of medical records needed to be further improved. Conclusion：Through the supervision of medical behavior more standardized，hospital and medical insurance coordinated management，jointly safeguard the security of medical insurance fund. |
| Key words: Medical Insurance Fund,DRG,Medical Insurance Supervision,Intelligent Supervision |
