Application of an intelligent audit system for medical insurance management at public hospitals / 中华医院管理杂志

ABSTRACT

By analyzing the medical insurance policy, the medical insurance audit business and the intelligent monitoring requirements put forward by the medical reform, the intelligent examination and approval database was established, and the system process reengineering was carried out in conjunction with HIS, LIS and electronic medical record systems. The intelligent medical insurance audit information system was successfully developed and implemented, which realized automatic review of the medical qualifications of trauma patients, automatic audit of blood product items, automatic verification of high-cost fees, automatic review of repeated hospitalizations within 10 days, and automatic update of discharge diagnosis, as well as drug( diagnosis/treatment) project limits( excessive) early warning and other core business functions. The system meets the actual needs of the quality and efficiency of data management in medical insurance audit, providing basic platform and data support for standardizing doctors′diagnosis and treatment behavior and avoiding hospital risks.