Design and application of medical institutions′ intelligent medical insurance audit system / 中华医院管理杂志

ABSTRACT

In recent years, the medical insurance coverage of China has been increased significantly, and the medical insurance policies have been launched continuously, so the traditional manual audit method is unable to support medical institutions to effectively supervise the medical insurance fund. In view of this situation, a tertiary hospital in Beijing had successfully built an intelligent medical insurance audit system for drugs, diagnosis and treatment projects under key supervision, realized the prior audit and in-process control of the illegal use of medical insurance funds, through the establishment of intelligent audit rules, the design of audit trigger points and the interception level of illegal medical orders, and the establishment of a pre-operational preparation system and continuous improvement mechanism. In March 2021, the hospital officially launched the system. After the application of the system, the amount and quantity of outpatient medical insurance refusal from April to September 2021 were 10 587 yuan and 72 respectively, which decreased by 79.21% and 77.50% compared with the same period in 2020. This system effectively improved the quality and efficiency of medical insurance fund supervision.