对医保医师提供的纳入医保支付范围的医疗服务行为加强监管是医保经办机构的重要职能之一。本文以上海市定点医疗机构门诊执业医师为研究对象,深入挖掘分析其执业行为,通过统一视图建设,从个人信息、资格信息、出诊信息和接诊患者信息四方面建立医师画像。同时立足医保经办业务需求,从模型建立、模型验证以及实证运用分析三方面探索经办业务规律,进一步规范医保医师诊疗行为,保障基金安全。

One of the core responsibilities of health insurance agency is to supervise doctors who accept insurant of basic health insurance. The paper takes certified doctors who work in outpatient department of designated medical institutions in Shanghai as the research object, conducts data mining of their behaviors, and builds doctor profile based on four types of data, including personal information, doctor certificates, physician round and patient information to present a unified view of patterns. Meanwhile, the paper explores the laws of medical health handling through three steps of model building, model validation and empirical analysis, in order to standardize doctors’ behavior and protect the healthcare security fund.