摘要
常态化监管体系下,面对医保监管对象众多、资金量庞大、结算数据海量的新形势、新挑战,医保智能监控成为基金监管的必备工具、重要手段及技术支撑。本文通过梳理回顾国家医保局成立以来的常态化监管新举措,分析医保智能监控的必要性和意义;以某省（市）为例,应用专家访谈法及问卷调查法调查统筹区医保经办机构的智能监控手段应用现状;提出构建我国医保智能监控体系及推进地区应用的优化策略。
Abstract
Under the normal supervision system, facing the new situation, challenges of numerous medical insurance supervision objects, huge amount of funds, massive settlement data, medical insurance intelligent monitoring is an essential tool, important means, technical support for medical insurance fund supervision. This paper reviews the new measures of medical insurance regular supervision since the establishment of the National Healthcare Security Administration, analyzes the necessity, importance of medical insurance intelligent monitoring. Taking a provincial administrative region as an example, this paper investigates the current application of the medical insurance intelligent monitoring system with expert interview, questionnaire survey, puts forward suggestions on the construction of the medical insurance intelligent monitoring system in China, the promotion of regional applications
关键词
医疗保障 /
基金监管 /
智能监控
Key words
medical insurance /
fund supervision /
intelligent monitoring
符美玲, 陈锦, 张伟, 孙玉梅, 刘英, 陈艺, 肖明朝, 陈登菊.
常态化监管体系下医保智能监控应用现状及优化策略研究[J]. 中国医疗保险. 2024, 0(6): 73-80 https://doi.org/10.19546/j.issn.1674-3830.2024.6.010
Research on Current Application and Optimization Strategy of Medical Insurance Intelligent Monitoring System Under Normal Supervision[J]. China Health Insurance. 2024, 0(6): 73-80 https://doi.org/10.19546/j.issn.1674-3830.2024.6.010
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参考文献
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[2] 国家医疗保障局.国新办举行加强医疗保障基金使用常态化监管国务院政策例行吹风会[EB/OL].(2023-06-09)[2023-09-23].http://www.nhsa.gov.cn/art/2023/6/9/art_14_10782.html.
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[5] 国家医疗保障局.国新办举行“权威部门话开局”系列主题新闻发布会介绍“贯彻落实党的二十大重大决策部署着力推动医保高质量发展”有关情况[EB/OL].(2023-05-18)[2023-09-23].http://www.nhsa.gov.cn/art/2023/5/18/art_14_10627.html.
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基金
重庆市教委人文社会科学研究项目“基于委托代理理论的疾病诊断相关分组医保支付制度对医疗服务供方行为的影响研究”（23SKGH044）; 2022年重庆医科大学附属第一医院管理基金“DRG支付制度下医院医疗服务监管体系的构建研究”（GLJJ2022-01）; 2022年重庆医科大学附属第一医院管理基金“医疗服务价格全流程智能审核系统在临床计费管理中的应用研究”（GLJJ2022-05）
