Developing Intelligent Auditing Methods to Deal with Up-coding under DRG payment system

doi:10.19546/j.issn.1674-3830.2022.6.009

China Health Insurance ›› 2022, Vol. 0 ›› Issue (6) : 44-47. DOI: 10.19546/j.issn.1674-3830.2022.6.009

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Developing Intelligent Auditing Methods to Deal with Up-coding under DRG payment system

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Abstract

“Up-coding” under the diagnosis-related group payment refers to the behavior that providers deliberately and systematically change the reported case mix in order to obtain more medical insurance payment, which brings risks to the security of medical insurance funds. In 2021, the National Healthcare Security Administration proposed to achieve full coverage of regions, medical institutions, disease groups and medical insurance funds based on DRG/DIP payments in the next three years. As the most destructive behavior, up-coding should be the focus of supervision. The traditional manual auditing method is inefficient, and international experience prefers the comprehensive supervision mode of computer-aided intelligent auditing. This paper systematically summarizes the methods and development of dealing with DRG up-coding, and proposes paths and suggestions to develop intelligent audit means in dealing with DRG up-coding in China.

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Developing Intelligent Auditing Methods to Deal with Up-coding under DRG payment system[J]. China Health Insurance. 2022, 0(6): 44-47 https://doi.org/10.19546/j.issn.1674-3830.2022.6.009

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