CAJ | 학술논문

分析了医院医保拒付管理的现状及存在的问题：医院在医保拒付管理过程中，除了要面对自身存在的不合理行为、病历质量缺陷、以及物价管理和医保管理存在不足等问题之外，还要积极应对卫生行政和物价主管部门在物价管理、医保经办机构在协议管理和稽核管理、患者在就医行为等方面存在的问题。在此基础上，提出了与卫生行政、物价、医保主管部门建立良性互动关系、健全物价管理体系、完善医保质量管理体系、加强对患者的引导和监管等具体对策。
분석료의원의보거부관리적현상급존재적문제：의원재의보거부관리과정중，제료요면대자신존재적불합리행위、병력질량결함、이급물개관리화의보관리존재불족등문제지외，환요적겁응대위생행정화물개주관부문재물개관리、의보경판궤구재협의관리화계핵관리、환자재취의행위등방면존재적문제。재차기출상，제출료여위생행정、물개、의보주관부문건립량성호동관계、건전물개관리체계、완선의보질량관리체계、가강대환자적인도화감관등구체대책。
The current situation and problems existing in medical insurance refusal payment management in hospital including the problems existing in hospital, such as irrationality in medical treatment, defects in medical records, deficiency in medical service price management and medical insurance management, and the problems derived from provincial health department, price bureau, medical insurance management center and the patients are analyzed. Based on the discussion, the countermeasures, such as found a positive interaction with the competent departments, improve the management system for price and medical insurance and strengthen the guide and supervising of patients are proposed.