血液透析领域是医保部门提供服务保障和基金监管的重点之一。2022年5月,国家医保局等四部门公布《2022年度医疗保障基金飞行检查工作方案》,首次明确对定点医疗机构血液透析等领域纳入医保基金支付范围的医疗服务行为和医疗费用进行检查。本研究基于聚类、时间序列、自然语言处理等大数据分析技术,提出建立以政策配置层、大数据分析（数据仓库）层、临床诊疗分析层、异常趋势分析层、结果输出层为主要流程的血液透析领域医保基金监管路径,并分析该路径在医保监管工作中的应用前景。
Abstract
The field of hemodialysis is among priorities of the medical insurance department in providing service guarantee and fund supervision. In May 2022, four sectors including the National Healthcare Administration announced the Work Plan for the Unannounced Inspection of the Medical Security Fund in 2022, which for the first time explicitly checked the medical service behavior and medical expenses of designated medical institutions in areas such as hemodialysis that are included in the payment scope of the medical insurance fund. Based on big data analysis technologies such as clustering, time series and natural language processing, this research proposes to establish a medical insurance fund supervision path in the field of hemodialysis with policy configuration layer, algorithm technology layer (data warehouse), clinical diagnosis and treatment analysis layer, abnormal trend analysis layer and result output layer as the main process, and analyzes the application prospect of this path in medical insurance supervision.
关键词
血液透析 /
医保基金监管 /
路径
Key words
hemodialysis /
supervision of medical insurance fund /
route
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