Discussion on the Audit Examples Based on DIP&#x02014;&#x02014;Taking a City in Fujian Province as an Example

doi:10.19546/j.issn.1674-3830.2023.8.016

China Health Insurance ›› 2023, Vol. 0 ›› Issue (8) : 101-105. DOI: 10.19546/j.issn.1674-3830.2023.8.016

Discussion on the Audit Examples Based on DIP——Taking a City in Fujian Province as an Example

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Abstract

This article extracts the medical insurance settlement list data of all inpatient cases from a tertiary hospital in a city of Fujian Province in 2022 to study the audit methods under the DIP payment. By analyzing the logic of diagnosis and all surgeries and procedures, the deviation of expenses within groups, and the distribution of medical institutions within groups, the paper summarizes the hospital alienation behaviors under DIP settlement, and offers policy suggestions and methods to further strengthen the precise supervision of medical insurance funds.

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DIP payment / medical insurance fund / supervision / audit

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Discussion on the Audit Examples Based on DIP——Taking a City in Fujian Province as an Example[J]. China Health Insurance. 2023, 0(8): 101-105 https://doi.org/10.19546/j.issn.1674-3830.2023.8.016

References

[1] 厦门市统计局,厦门市第七次全国人口普查领导小组办公室.厦门市第七次全国人口普查公报[R/OL].(2021-05-21)[2023-07-02].http://tjj.xm.gov.cn/zfxxgk/zfxxgkml/tjsjzl/ndgb/202105/t20210527_2554550.htm.
[2] 厦门市医疗保障局.关于印发厦门市医疗保障定点医疗机构住院区域点数法总额预算和按病种分值付费(DIP)规程等2个文件的通知:厦医保〔2021〕8号[A/OL](2021-09-02)[2023-07-02].http://ylbz.xm.gov.cn/zwgk/zfxxgk/ml/zcwj/zcfg/202109/t20210902_2580292.htm.
[3] 张计美,孟文竹.DIP付费对公立医院运营管理的影响探析[J].商业会计,2021,711(15):103-106.
[4] 朱旭林,龚熠,郭丽娟,等.医保基金监管的方式、成效与困境[J].卫生经济研究,2021,38(09):49-52.
[5] 朱敏,李红艳,魏倩如.医疗保险基金智能监管模式建构和运作研究[J].卫生经济研究,2021,38(06):40-43.
[6] 国务院.医疗保障基金使用监督管理条例:中华人民共和国国务院令第735号[A/OL].(2021-02-20)[2023-07-02].https://www.gov.cn/gongbao/content/2021/content_5591403.htm.
[7] 郁辉.赢利性制度逻辑下的医疗异化行为及医患冲突[J].中国医院管理,2012,32(11):70-71.
[8] BAUDERR,SELIYA N, KHOSHGOFTAART M.A survey on the state of healthcare upcoding fraud analysis and detection[J].Health services & outcomes research methodology, 2017.
[9] 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.
[10] 冯芳龄,胡希家,叶向明,等.DRG与DIP助力公立医院高质量发展的政策内涵及改革实践——“DRG及公立医院高质量发展研讨会”综述[J].卫生经济研究,2021,38(08):35-38.
[11] 黄德斌,秦佳佳,毛勇全.发挥医保数据监测和警示作用的创新之路——基于成都市医保大数据挖掘的实践[J].中国医疗保险,2017,104(05):38-41.
[12] 周吴平,简伟研.以智能审核应对DRG高靠分组问题[J].中国医疗保险,2022(06):44-47.
[13] EKIN T, LEVA F, RUGGERI F, et al.Statistical Medical Fraud Assessment:Exposition to an Emerging Field[J].International Statistical Review, 2018,86(3):379-402.
[14] AKBAR N A, SUNYOTO A, ARIEF M R, et al.Improvement of decision tree classifier accuracy for healthcare insurance fraud prediction by using Extreme Gradient Boosting algorithm[J].IEEE journal of 2020 International Conference on Informatics, Multimedia, Cyber and Information System (ICIMCIS),2020:110-114.
[15] FERRAND Y, KELTON C M, GUO J J, et al.Using time-series intervention analysis to understand U.S.Medicaid expenditures on antidepressant agents[J].Res Social Adm Pharm.2011 Mar, 7(1):64-80.