Research On Medical Insurance Management Of A General Hospital On PDCA Cycle

Objective: to analyze the problems existing in the medical insurance management of a hospital,formulate targeted intervention measures,introduce PDCA cycle quality control method,and achieve the purpose of reducing the medical insurance intelligent audit refusal,reducing the total amount of the assessment commitment,promoting the rational use of drugs,standardizing clinical treatment,billing behavior,and reducing the burden of patients in hospital.Methods: 1.Based on the analysis of the data of the past medical insurance intelligent audit,combined with face-to-face and semi-structured interviews,this paper analyzes the reasons for the refusal of medical insurance intelligent audit,so as to provide the basis for the development of intervention measures;2.Analyze the differences of the overall payment and actual average cost of each disease in 2018 between the hospital and the same disease in the same level hospitals in the city,and screen out The disease with poor cost control can provide reference for medical insurance training and clinical training.At the same time,by comparing the cost of the disease with that of the medical institutions with better cost control,we can find out the causes of the poor cost control,and provide reference for the formulation of management measures;3.Introduce PDCA cycle quality management method,and continuously supervise,analyze,modify and improve the intervention measures.Results: The data analysis before the intervention shows that: a.the main violation rule of medical insurance intelligent audit refusal is to limit the indications(conditions)of drug use,which is also the main reason for drug refusal.At the same time,drug refusal is concentrated on a few types of drugs,and all of them violate the limited indications(conditions),while other types of drug refusal are relatively scattered,so it is difficult to intervene,and some of them have the phenomenon of repeated mistakes and offenses;B.the hospital has a total of 108 diseases,all of which pay more than the average of the same level,and the first five diseases with more diagnoses are respiratory diseases;C.general Through the analysis of the cost data of bronchopneumonia in hospital a,it is found that the average total hospitalization cost of medical insurance patients in hospital a is higher than that of patients at their own expense;hospital a is higher than hospital B in the cost of examination and test,diagnosis and treatment.The data analysis after intervention showed that: a.the number of records of refusal to pay in the intelligent audit of medical insurance decreased compared with that before intervention,and the deduction rate and the number of times of declaration all showed a gradual decline trend,and the amount of refusal to pay for drugs decreased significantly;B.after intervention,the total cost of different payment types of bronchopulmonary inflammation patients had no significant difference,and the average total cost of medical insurance patients decreased;C.the number of times increased The amount of recognition and the average sub average fee can be significantly increased.The total amount of assessment commitment under total control decreased significantly.Conclusion: Based on PDCA cycle in the hospital medical insurance management has achieved good results,for reducing the medical insurance audit refused to pay,reducing the hospital total amount control assessment amount has a significant advantage.However,there are some defects in the management of non payment fees for other types of projects in the intelligent assisted audit of medical insurance.