Research On Compliance Management Of Basic Medical Insurance In Suzhou F Hospital

The National Health Security Administration has strengthened the depth of legislation and enforcement of the health insurance system in response to the expansion of health insurance reform and the promotion of a thorough rule of law.Besides,the wide range of regulatory tools and strict regulatory system have guided and pushed the administration of the health insurance system in the direction of compliance.Compliance management,as a new direction of organizational business process management,has been widely used in various organizations and businesses in recent years,but it has rarely been applied in hospital management practice.The National Health Security Administration and each designated medical institution are included in the administration of basic medical insurance as a component of the medical security system.Thus,the management of basic medical insurance compliance in hospital management practice has steadily emerged as an important research area,along with the reform of medical insurance payment methods and the demands of high-quality development of public hospitals.This paper follows the methodology of "current situation analysis-issue identification-problem solving" to conduct an organized and thorough study on the compliance management of basic medical insurance in F hospital.First,from the perspectives of government regulation theory and system theory,this paper compares the policies and regulations put forth by our nation with the regulatory documents published by hospital associations,concentrating on two documents,namely the Regulations on Supervision and Management of Medical Insurance Fund Use and the Hospital Medical Insurance Service Standards.Based on the Donabedian model,field research using a combination of the questionnaire and interview methods was used to compile a summary of the management initiatives and successes of basic medical insurance management in the current medical insurance management process in F hospital.Secondly,the existing rules and hospital association norms are compared to identify the difficulties in F Hospital’s present compliance management,such as variations in the implementation and design of the hospital’s basic medical insurance system,the organization of compliance management is not yet complete,the management process has not been implemented,the assessment mechanism is not flawless and there are also risks of integrity and self-discipline.The seven core components of the Compliance Management System Guidelines are covered in-depth in relation to the causes of the issues.Finally,the principle of resolving the current compliance management quandary in F hospitals is taken into consideration,along with government regulation theory,system theory,and public value theory,and the optimal route for developing a compliance management system of basic medical insurance in hospitals is suggested.Internal improvements to the hospital’s basic medical insurance compliance management system could be made by creating a compliance organization,enhancing the system,focusing on compliance culture and taking a leadership role,implementing compliance activities to achieve good support,conducting thorough assessments,and conducting good evaluations.Additionally,it is anticipated that the hospital’s basic medical insurance compliance management system will be improved by stepping up supervision,enhancing the improvement process,and putting other efforts into practice.These enhancements are intended to support the hospital’s high-quality development.