CAJ | 학술논문

目的：通过分析医院门诊内科医保拒付情况，为降低医保拒付和促进合理治疗提供参考依据。方法统计某医院2012年～2014年门诊内科系统各科室医保拒付数据，对医保拒付情况进行描述性分析。结果在2012年到2014年间，某医院门诊内科系统共发生医保拒付4854例，拒付费用达15.9万元，其中心脏中心就诊人次数最多，产生医保拒付次数最多，为2226例，拒付金额为45214元。拒付原因以累计开药超量和单次开药超量为主，分别占总次数的80％和15％。结论通过分析医院门诊内科医保拒付情况，可以及时制定医保管理制度和多部门动态对接医保政策等改进措施，可有效降低医保拒付现象的发生。
목적：통과분석의원문진내과의보거부정황，위강저의보거부화촉진합리치료제공삼고의거。방법통계모의원2012년～2014년문진내과계통각과실의보거부수거，대의보거부정황진행묘술성분석。결과재2012년도2014년간，모의원문진내과계통공발생의보거부4854례，거부비용체15.9만원，기중심장중심취진인차수최다，산생의보거부차수최다，위2226례，거부금액위45214원。거부원인이루계개약초량화단차개약초량위주，분별점총차수적80％화15％。결론통과분석의원문진내과의보거부정황，가이급시제정의보관리제도화다부문동태대접의보정책등개진조시，가유효강저의보거부현상적발생。
Objectives Through conducting analysis on the payment refusal of medical insurance in outpatient internal medicine department, to provide reference basis to reduce the payment refusal and promote the reasonable treatment. Methods The data about the payment refusal in all the outpatient internal medicine departments in a hospital from 2012 to 2014 was collected, and made a descriptive analysis on the refusal situations. Results There were 4854 cases of payment refusal in the outpatient internal medicine departments in a hospital from 2012 to 2014, and the total expense was 159000 yuan. The heart center got the most admitted patients which was 2226 cases, and also got the most refusal expense which was 45214 yuan. The reasons for payment refusal mainly contributed to cumulative prescribing excess and single prescribing excess, which accounted for 80% and 15% respectively. Conclusions By analyze the situation of payment refusal of medical insurance in outpatient internal medicine department, we could make improving measures such as formulating medical insurance management rules timely as well as dynamic connection to medical insurance policy by multiple departments, which could decrease the occurrence of payment refusal of medical insurance effectively.