摘要
随着DRG/DIP支付方式改革的不断推进,DRG/DIP付费下新出现的高靠编码等违规使用医保基金行为逐渐突显,而这些行为在《医疗保障基金使用监督管理条例》（以下简称《条例》）中尚无完全对应的表述和定义。这些违规行为依何处理、如何处理、怎样定损在全国范围内尚无科学、统一、可操作的实践标准。基于上述背景,本文分析了DRG/DIP付费下医疗机构违规行为认定及处理过程中存在的问题,阐述了DRG/DIP付费下医疗机构违规行为与《条例》中具体条目的一一对应关系,探讨了DRG/DIP付费下医保基金的定损方式,为进一步提高医保部门的行政执法能力及医保基金精细化管理水平提供理论依据。
Abstract
With the continuous promotion of DRG/DIP payment reform, the newly emerged illegal use of medical insurance fund such as upcoding is becoming more prominent, and there is no corresponding expression and definition of these behaviors in The Regulations on the Supervision and Administration of the Use of Healthcare Security Funds (hereinafter referred to as The Regulations). There is no scientific, unified, and operable practical standard nationwide on the basis, solution, and loss assessment of these violations. Therefore, this paper focuses on the issues existed in identification and treatment of hospitals' violations under DRG/DIP payment, explains the one-to-one correspondence among the violations and the specific items in The Regulations, and discusses the accurate way to determine the damage to the healthcare security fund under DRG/DIP payment, which provides theoretical basis for further improving the administrative law enforcement ability of the healthcare security department and the refined management of the healthcare security fund.
关键词
DRG /
DIP /
支付方式改革 /
违规行为监管 /
医保基金定损
Key words
DRG /
DIP /
payment reform /
regulation of violations /
loss assessment of healthcare security fund
赵辉.
DRG/DIP付费下医疗机构违规行为的认定依据及处理模式研究[J]. 中国医疗保险. 2023, 0(11): 103-109 https://doi.org/10.19546/j.issn.1674-3830.2023.11.014
Research on the Identification Basis and Treatment Mode for the Violation Behavior of Medical Institutions Under DRG/DIP Payment[J]. China Health Insurance. 2023, 0(11): 103-109 https://doi.org/10.19546/j.issn.1674-3830.2023.11.014
{{custom_sec.title}}
{{custom_sec.title}}
{{custom_sec.content}}
参考文献
[1] 王东进.学好用好《条例》开启医保基金使用监管新局[J].中国医疗保险,2021(05):14-16.
[2] 倪沪平.医保基金监管条例中三类法律责任辨析[J].中国社会保障,2021(03):43.
[3] 国家医疗保障局.2022年全国医疗保障事业发展统计公报[EB/OL].(2023-07-10)[2023-08-10].http://www.nhsa.gov.cn/art/2023/7/10/art_7_10995.html.
[4] 国家医疗保障局.国家医疗保障疾病诊断相关分组(CHS-DRG)分组与付费技术规范[EB/OL].(2019-09-10)[2023-08-10].https://www.gov.cn/zhengce/zhengceku/2019-11/18/5562261/files/d1e38788efee4493b732fdcb0776a2b7.pdf.
[5] 国家医疗保障按病种分值付费(DIP)技术规范[EB/OL].(2020-10-10)[2023-08-10].https://www.gov.cn/zhengce/zhengceku/2020-11/30/5565845/files/8242d69ea79846d185f9048d52edb6c7.pdf.
[6] 廖藏宜,张艺艺.DRG/DIP付费下异化行为表现及监管建议[J].中国医疗保险,2023(02):27-34.
[7] 张智勇,徐强.DRG/DIP基金监管的新挑战新思考[EB/OL].(2023-02-10)[2023-07-10].https://mp.weixin.qq.com/s/710LamjEA3F_Rbwakp_vTg.
[8] 段政明.浅谈《医疗保障基金使用监督管理条例》[J].中国医疗保险,2021(06):17-20.
[9] 开封市医疗保障局.开封市按疾病诊断相关分组 (DRG)付费监督管理办法(试行)[EB/OL].(2022-09-30)[2023-07-10].http://ylbzj.kaifeng.gov.cn/news/23011023_policydel.html.
[10] MILCENT C.From downcoding to upcoding:DRG based payment in hospitals[J].International journal of health economics and management, 2021, 21(1):1-26.
[11] ROSENBERG M A, FRYBACK D G, KATZ D A.A statistical model to detect DRG upcoding[J].Health services and outcomes research methodology, 2000(1:)233-252.
[12] STEINBUSCH P J M, OOSTENBRINK J B, ZUURBIER J J, et al.The risk of upcoding in casemix systems:a comparative study[J].Health policy, 2007, 81(2-3):289-299.
[13] 孙淑云.医保行政监督与经办协议管理的边界和协同[J].中国医疗保险,2021(6):4.
[14] 仇雨临,王昭茜.共建共治共享建设协同医保[J].中国医疗保险,2022(01):1-3.
