目的: 分析超声检查费用的医保拒付现状及影响因素,并有针对性地提出对策建议。方法: 本文基于浙江省某三甲医院2023—2024年超声检查项目医保拒付数据,以现行浙江省医保支付政策为依据,采用描述性统计分析方法对超声项目的医保拒付进行原因分析。结果: 整体而言,各年龄组的医保支付合规率呈现出(0,14]岁低年龄组高,(14,40]岁青壮年年龄组低,(40,70]岁中老年年龄组呈上升趋势,而(70,100]岁高龄组低的特征。此外,普通门诊的整体合规率最低。深入分析发现,同一日内同一项目检查数量越多则支付率越低;非肿瘤病人超频次、重复收费和超检查部位是拒付的主要原因。结论: 建议优化医保支付政策、规范医疗操作和提升医院管理赋能来协调患者、医保和医院三方的医疗服务事业,进而促进医疗卫生事业高质量发展。

Objective: The study analyzes the current status and influencing factors of medical insurance refusal of payment for ultrasound examination fees, and puts forward targeted suggestions. Methods: Based on the data of medical insurance claim denials for ultrasound examination at a tertiary hospital in Zhejiang Province from 2023 to 2024, this study analyzed the reasons for claim rejections by applying descriptive statistical methods, in accordance with the current medical insurance reimbursement policies for ultrasound examination in Zhejiang Province. Results: Overall, the medical insurance payment compliance rate for each age group showed the characteristics of high rates in the low age group (0,14], low rates in the young-adult age group (14,40], an increasing trend in the middle-aged and old-aged age group (40,70], and low rates in the high-age group (70,100]. Additionally, the overall compliance rates of general outpatient clinics were the lowest. In-depth analysis revealed that the higher the number of examinations of the same item on the same day, the lower the payment rate. The non-oncology patient over-frequency, double billing and over-examined sites were the main reasons for denial of payment. Conclusion: We propose to optimize medical insurance reimbursement policies, standardize medical practices, and enhance hospital management empowerment to coordinate the healthcare service undertakings containing patients, medical insurance systems, and healthcare institutions, thereby promoting high-quality development in the healthcare sector.