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Since 2009, some hospitals in Beijing have begun to promote the use of patients with social security cards in the real-time settlement of hospital outpatient clinics. By 2010, all types of hospitals in Beijing will be fully implemented. This “card-to-card visit and real-time settlement†approach has changed the way patients in the past have paid for medical expenses in full in the outpatient visits, and then handed out various types of bills (such as prescriptions, receipts, laboratory tests, etc.) to the social security center for centralized processing. The inconveniences of reimbursement are directly reimbursed by the medical insurance institutions on a pro-rata basis, which greatly facilitates the patient's access to medical services and capital pressure, and allows the people to truly feel the convenience and benefits of the policy.
From the point of view of hospital management to analyze the real-time settlement of medical insurance, we found that the main process of this work is as follows: hospitals need to embed service components uniformly provided by medical insurance institutions in outpatient registration-related software (such as HIS software) when the patient seeks medical care and costs arise. , Through this business component, the patient's fees are decomposed and the bills are printed (except for the registration fee). The patient only needs to pay the self-paid portion outside the self-paid portion and scope of the medical insurance, and the remaining portion to be paid by the medical insurance fund will be passed by the medical insurance agency after the approval. Pay the hospital.
Looking at the above process, the work must inevitably reform and innovate the hospital's original management system, work model, and business process. Not only makes the hospital information construction face new challenges, but also puts forward new requirements for hospital financial management; at the same time, as an important Huimin project of the Beijing Municipal Government, it omits the direct economic burden on patients and occupies the relationship between doctors and patients. A decisive role. Therefore, while the hospital attaches great importance to this work, it should carefully sort out the problems and difficulties in the initial stage of social security card real-time settlement work, and put forward solutions to the ideas and suggestions, so that the work at the same time Huimin, It can also ensure the normal operation of the hospital and its own development, making the three peoples, the government, and the hospital achieve a harmonious and win-win situation and promote the health of Beijing's medical and health care industry.
I. Problems and difficulties encountered by hospitals in promoting real-time settlement management of medical insurance
1. Hospital charging system and medical insurance system are difficult to dock. The first problem faced by the hospital in implementing the real-time settlement of the medical maintenance card is related software support and compatibility issues. With the continuous development of informatization construction in recent years, the large-scale top-three hospitals have successively implemented diversified informatization software such as the charging system (HIS system), financial management system, material system, and fixed assets system. The medical insurance system required by the real-time settlement of medical insurance is provided by the medical insurance agency and needs to be effectively linked to the hospital outpatient billing system. The current difficulties faced by the hospital's charging system are: As the relevant government departments do not provide uniform hospital charging systems or uniform technical specifications, the hospitals have purchased and developed their own products. Therefore, there are various levels of fee collection system in each hospital. Connect with the software of the health insurance center. Only when the patient social security card number, name, gender and other basic information in the hospital charging system are strictly identical, can it be guaranteed to upload to the medical insurance system. However, the current status of the hospital charging system makes it difficult to connect with the medical insurance system, and the information inconsistency can easily occur. Medical insurance settlement efficiency increases the risk of medical insurance rejection.
2. At the same time that hospitals have increased the amount of money they have paid for medical insurance, the financial risks have also increased significantly. Different from the pre-paid billing methods for patients with out-patient medical insurance, the real-time settlement of the card will only require the card to pay part of the personal payment. The rest will be paid directly by the hospital and settled with the medical insurance department. The medical insurance center will review the data uploaded by the hospital and return it to the hospital for payment. If the unqualified data is reviewed for the cost of the payment, the hospital will need to re-upload it or be directly refused the payment. The reform of this settlement model has caused two difficulties for the hospital: First, because the real-time settlement of the card is a large amount of money advanced by the hospital, and the time for medical insurance payment can not be effectively guaranteed, this greatly aggravates the financial turnover of the hospital. , And the enormous pressure on the hospital working capital may lead to the triangle debt between the hospital, medical insurance and pharmaceutical companies, affecting the normal development of the hospital. Secondly, while the hospital is under huge financial pressure, the risk of being refused by the medical insurance center is also transferred from the patient to the hospital. According to relevant requirements, only the outpatient medical service of the hospital can be reasonably treated with medical treatment, reasonable medication, and reasonable expenses. Being refused by the Medicare Center made the hospital responsible for the rigorous regulation and supervision of medical behaviors, which undoubtedly increased the risk of the hospital being rejected, and at the same time increased the difficulty of reconciliation and recovery of the medical department's reimbursement in the financial department.
3. For the real-time settlement of medical insurance, financial personnel face new challenges. The implementation of real-time settlement of cardholders has increased the time for card swiping and cost decomposition in the original waiting time. In order to reduce waiting time for patients, the financial department needs to set up more charging windows at the charging office, and also needs to complete the establishment of outpatient medical receivables. Detailed accounts, data uploads, blending media, verification of Medicare paybacks, detailed accounting, changes in accounting and other tasks. This requires that both the window charging staff and the account checking staff should be familiar with the health insurance policy. If the patient has doubts about the inconsistency between the refund fee and the current occurrence fee in cash payment, it will cause the insured personnel to stay in the window. Problems such as the extension of waiting time for inquiries, registrations and payment of fees, and disorderly delivery of fees, etc., may lead to contradictions between doctors and patients. Therefore, how to solve the problem of toll collectors and arrange division of labor to do the above work is a job challenge faced by financial personnel.
Second, solve the problem of ideas and countermeasures
1. The hospital information construction should be unified standards. With the industrialization of hospital information systems, there are more than 2,000 HIS system software development companies in China. However, although hospitals at all levels choose HIS systems of different companies to meet their own development needs, most HIS systems have problems such as repeated development, lack of a unified industry standard, and immature technology, and thus change in settlement methods and system transformation process. In addition, the hospitals still need to invest a lot of people, things, and money to improve the system transformation. From the perspective of the allocation of resources in the entire health industry, the resources of the hospitals cannot be rationally and effectively configured, and the phenomenon of medical wastes occurs from time to time. In the real-time settlement of the health insurance HIS reform this phenomenon is more significant, such as each hospital will have to pay the cost to the software development company to transform.
Proposals should be made by the hospital industry authorities in the Beijing region to classify hospitals according to hospital level or specialty type, establish a unified, mandatory HIS system access standard, or purchase related software, and gradually expand to logistics systems and fixed asset systems. And other information types. This will not only make the data integration and analysis of the health system more effective, but also help the health industry as a whole interface with the medical insurance or other industries. Specific reference can be made to the unification of the financial related software of Beijing hospitals: Beijing hospitals and district hospitals as early as 1999 were uniformly procured by the Bureau of Health and asked the hospital to use Jin Ao financial software for accounting. In real time today, regular collection and major upgrades of all financial data can be efficiently completed under the overall plan of the Health Bureau. On this basis, municipal hospitals have also realized the integration of cost accounting, budget management and other related software.
2. Hospitals should improve internal management and strengthen external coordination. After the implementation of the real-time settlement of the medical insurance card, the hospital has made the original limited cash flow even more difficult, and the risk of the medical insurance refusal to pay has also become more apparent than before. Therefore, the large amount of hospital advanced funds, the time is too long, the patient's medical expenses can not be promptly recovered as the difficulty and focus of the medical insurance work, but also an important issue affecting the use of hospital funds. The idea of ​​solving this problem is mainly considered from the inside and outside of the hospital:
Internally, hospitals should actively improve their internal management. First of all, medical personnel should strictly implement the medical insurance system and improve hospital quality management. In order to broaden the publicity efforts of health care workers, the medical insurance system should establish a code of conduct among medical personnel and strengthen medical ethics education. Emphasis should be placed on the rational use of medicines, the treatment of diseases, the elimination of prescriptions and human emotions, and the failure to use valuable drugs as much as possible. . Strictly referring to the medical insurance system, so as to effectively shut down the medical insurance because of unreasonable medical behavior and refused to pay. Second, the accuracy of medical insurance settlement and information transmission should be improved. The real-time settlement of medical insurance is a concrete realization of the implementation of the medical insurance policy in the hospital. The settlement personnel should effectively intercept the wrong information, blacklists, diseases outside the medical insurance policy and other factors, so that the settlement is accurate, and timely upload to the social security center as required, thereby increasing the Medical insurance payment rate.
From an external point of view, it is an objective and realistic problem for hospitals to use a large amount of funds after real-time settlement, which will inevitably affect the use of hospital funds and hospital development. Under the existing medical insurance system, the problem of large-scale capital occupation depends on the difficulty of hospital individuals alone. Therefore, it is necessary for hospitals and health authorities to actively coordinate and promote the effective communication between the health authorities and the medical insurance department and protect the hospital from the policy. healthy growth. Can learn from ideas such as: the government can consider Medicare reimbursement from the current post-payment system to pre-paid and post-payment system. That is to say, the medical insurance institution sets the basic amount according to the amount of medical insurance settlement for the previous two years of the hospital, and pays it to the hospital in advance according to a certain proportion, and the remaining part can gradually pay according to the current method according to the settlement situation. This method can effectively alleviate the shortage of funds in hospitals and provide impetus to hospitals to improve service quality and implement medical insurance policies.
3. Strengthen the training of financial personnel and improve the level of medical insurance business. Personnel training is a long-term job involving people, finances, and materials. In the process of continuously improving the real-time settlement of social security cards, it should be based on the actual situation of the hospital, and be divided into batches and phases. staff training. In accordance with the implementation of real-time settlement requirements, combined with real-time settlement manuals and higher authorities in the relevant system of medical insurance as training materials. The relevant personnel of the hospital and the engineers of the software company are responsible for personnel training tasks, and they will explain in detail specific problems and simulate actual operations. The outpatient and fee-clearing settlement personnel must pass the relevant software's actual operation level test. In addition, in addition to proficient in health insurance policies and related software, the clearing staff should also understand the proportion of self-financed A, B, inspection and high-value consumables commonly used, so as to be able to decompose and record health insurance costs, ensure the accuracy of relevant information. And efficient.
In short, under the current new medical reform situation, “difficult in seeing a doctor and expensive to see a doctor†is not only a problem in the mechanism and system, but also a major livelihood issue that concerns the health of the people. Being treated as a doctor is one of the basic requirements of human beings and one of the most basic responsibilities of society. The medical insurance system is the people's livelihood project. It is incumbent responsibility to manage and use health insurance costs. Social security card real-time settlement is the challenge that the hospital will face. The payment method and settlement method of medical insurance is the core content of medical insurance management. Any settlement method is not a panacea, and it will have its own defects and weaknesses. This requires the We continue to explore and boldly innovate to make medical insurance management and hospital management embark on a path of healthy, harmonious and sustainable development, and to promote hospitals to become people-oriented service-oriented and scientific development learning organizations.
From the point of view of hospital management to analyze the real-time settlement of medical insurance, we found that the main process of this work is as follows: hospitals need to embed service components uniformly provided by medical insurance institutions in outpatient registration-related software (such as HIS software) when the patient seeks medical care and costs arise. , Through this business component, the patient's fees are decomposed and the bills are printed (except for the registration fee). The patient only needs to pay the self-paid portion outside the self-paid portion and scope of the medical insurance, and the remaining portion to be paid by the medical insurance fund will be passed by the medical insurance agency after the approval. Pay the hospital.
Looking at the above process, the work must inevitably reform and innovate the hospital's original management system, work model, and business process. Not only makes the hospital information construction face new challenges, but also puts forward new requirements for hospital financial management; at the same time, as an important Huimin project of the Beijing Municipal Government, it omits the direct economic burden on patients and occupies the relationship between doctors and patients. A decisive role. Therefore, while the hospital attaches great importance to this work, it should carefully sort out the problems and difficulties in the initial stage of social security card real-time settlement work, and put forward solutions to the ideas and suggestions, so that the work at the same time Huimin, It can also ensure the normal operation of the hospital and its own development, making the three peoples, the government, and the hospital achieve a harmonious and win-win situation and promote the health of Beijing's medical and health care industry.
I. Problems and difficulties encountered by hospitals in promoting real-time settlement management of medical insurance
1. Hospital charging system and medical insurance system are difficult to dock. The first problem faced by the hospital in implementing the real-time settlement of the medical maintenance card is related software support and compatibility issues. With the continuous development of informatization construction in recent years, the large-scale top-three hospitals have successively implemented diversified informatization software such as the charging system (HIS system), financial management system, material system, and fixed assets system. The medical insurance system required by the real-time settlement of medical insurance is provided by the medical insurance agency and needs to be effectively linked to the hospital outpatient billing system. The current difficulties faced by the hospital's charging system are: As the relevant government departments do not provide uniform hospital charging systems or uniform technical specifications, the hospitals have purchased and developed their own products. Therefore, there are various levels of fee collection system in each hospital. Connect with the software of the health insurance center. Only when the patient social security card number, name, gender and other basic information in the hospital charging system are strictly identical, can it be guaranteed to upload to the medical insurance system. However, the current status of the hospital charging system makes it difficult to connect with the medical insurance system, and the information inconsistency can easily occur. Medical insurance settlement efficiency increases the risk of medical insurance rejection.
2. At the same time that hospitals have increased the amount of money they have paid for medical insurance, the financial risks have also increased significantly. Different from the pre-paid billing methods for patients with out-patient medical insurance, the real-time settlement of the card will only require the card to pay part of the personal payment. The rest will be paid directly by the hospital and settled with the medical insurance department. The medical insurance center will review the data uploaded by the hospital and return it to the hospital for payment. If the unqualified data is reviewed for the cost of the payment, the hospital will need to re-upload it or be directly refused the payment. The reform of this settlement model has caused two difficulties for the hospital: First, because the real-time settlement of the card is a large amount of money advanced by the hospital, and the time for medical insurance payment can not be effectively guaranteed, this greatly aggravates the financial turnover of the hospital. , And the enormous pressure on the hospital working capital may lead to the triangle debt between the hospital, medical insurance and pharmaceutical companies, affecting the normal development of the hospital. Secondly, while the hospital is under huge financial pressure, the risk of being refused by the medical insurance center is also transferred from the patient to the hospital. According to relevant requirements, only the outpatient medical service of the hospital can be reasonably treated with medical treatment, reasonable medication, and reasonable expenses. Being refused by the Medicare Center made the hospital responsible for the rigorous regulation and supervision of medical behaviors, which undoubtedly increased the risk of the hospital being rejected, and at the same time increased the difficulty of reconciliation and recovery of the medical department's reimbursement in the financial department.
3. For the real-time settlement of medical insurance, financial personnel face new challenges. The implementation of real-time settlement of cardholders has increased the time for card swiping and cost decomposition in the original waiting time. In order to reduce waiting time for patients, the financial department needs to set up more charging windows at the charging office, and also needs to complete the establishment of outpatient medical receivables. Detailed accounts, data uploads, blending media, verification of Medicare paybacks, detailed accounting, changes in accounting and other tasks. This requires that both the window charging staff and the account checking staff should be familiar with the health insurance policy. If the patient has doubts about the inconsistency between the refund fee and the current occurrence fee in cash payment, it will cause the insured personnel to stay in the window. Problems such as the extension of waiting time for inquiries, registrations and payment of fees, and disorderly delivery of fees, etc., may lead to contradictions between doctors and patients. Therefore, how to solve the problem of toll collectors and arrange division of labor to do the above work is a job challenge faced by financial personnel.
Second, solve the problem of ideas and countermeasures
1. The hospital information construction should be unified standards. With the industrialization of hospital information systems, there are more than 2,000 HIS system software development companies in China. However, although hospitals at all levels choose HIS systems of different companies to meet their own development needs, most HIS systems have problems such as repeated development, lack of a unified industry standard, and immature technology, and thus change in settlement methods and system transformation process. In addition, the hospitals still need to invest a lot of people, things, and money to improve the system transformation. From the perspective of the allocation of resources in the entire health industry, the resources of the hospitals cannot be rationally and effectively configured, and the phenomenon of medical wastes occurs from time to time. In the real-time settlement of the health insurance HIS reform this phenomenon is more significant, such as each hospital will have to pay the cost to the software development company to transform.
Proposals should be made by the hospital industry authorities in the Beijing region to classify hospitals according to hospital level or specialty type, establish a unified, mandatory HIS system access standard, or purchase related software, and gradually expand to logistics systems and fixed asset systems. And other information types. This will not only make the data integration and analysis of the health system more effective, but also help the health industry as a whole interface with the medical insurance or other industries. Specific reference can be made to the unification of the financial related software of Beijing hospitals: Beijing hospitals and district hospitals as early as 1999 were uniformly procured by the Bureau of Health and asked the hospital to use Jin Ao financial software for accounting. In real time today, regular collection and major upgrades of all financial data can be efficiently completed under the overall plan of the Health Bureau. On this basis, municipal hospitals have also realized the integration of cost accounting, budget management and other related software.
2. Hospitals should improve internal management and strengthen external coordination. After the implementation of the real-time settlement of the medical insurance card, the hospital has made the original limited cash flow even more difficult, and the risk of the medical insurance refusal to pay has also become more apparent than before. Therefore, the large amount of hospital advanced funds, the time is too long, the patient's medical expenses can not be promptly recovered as the difficulty and focus of the medical insurance work, but also an important issue affecting the use of hospital funds. The idea of ​​solving this problem is mainly considered from the inside and outside of the hospital:
Internally, hospitals should actively improve their internal management. First of all, medical personnel should strictly implement the medical insurance system and improve hospital quality management. In order to broaden the publicity efforts of health care workers, the medical insurance system should establish a code of conduct among medical personnel and strengthen medical ethics education. Emphasis should be placed on the rational use of medicines, the treatment of diseases, the elimination of prescriptions and human emotions, and the failure to use valuable drugs as much as possible. . Strictly referring to the medical insurance system, so as to effectively shut down the medical insurance because of unreasonable medical behavior and refused to pay. Second, the accuracy of medical insurance settlement and information transmission should be improved. The real-time settlement of medical insurance is a concrete realization of the implementation of the medical insurance policy in the hospital. The settlement personnel should effectively intercept the wrong information, blacklists, diseases outside the medical insurance policy and other factors, so that the settlement is accurate, and timely upload to the social security center as required, thereby increasing the Medical insurance payment rate.
From an external point of view, it is an objective and realistic problem for hospitals to use a large amount of funds after real-time settlement, which will inevitably affect the use of hospital funds and hospital development. Under the existing medical insurance system, the problem of large-scale capital occupation depends on the difficulty of hospital individuals alone. Therefore, it is necessary for hospitals and health authorities to actively coordinate and promote the effective communication between the health authorities and the medical insurance department and protect the hospital from the policy. healthy growth. Can learn from ideas such as: the government can consider Medicare reimbursement from the current post-payment system to pre-paid and post-payment system. That is to say, the medical insurance institution sets the basic amount according to the amount of medical insurance settlement for the previous two years of the hospital, and pays it to the hospital in advance according to a certain proportion, and the remaining part can gradually pay according to the current method according to the settlement situation. This method can effectively alleviate the shortage of funds in hospitals and provide impetus to hospitals to improve service quality and implement medical insurance policies.
3. Strengthen the training of financial personnel and improve the level of medical insurance business. Personnel training is a long-term job involving people, finances, and materials. In the process of continuously improving the real-time settlement of social security cards, it should be based on the actual situation of the hospital, and be divided into batches and phases. staff training. In accordance with the implementation of real-time settlement requirements, combined with real-time settlement manuals and higher authorities in the relevant system of medical insurance as training materials. The relevant personnel of the hospital and the engineers of the software company are responsible for personnel training tasks, and they will explain in detail specific problems and simulate actual operations. The outpatient and fee-clearing settlement personnel must pass the relevant software's actual operation level test. In addition, in addition to proficient in health insurance policies and related software, the clearing staff should also understand the proportion of self-financed A, B, inspection and high-value consumables commonly used, so as to be able to decompose and record health insurance costs, ensure the accuracy of relevant information. And efficient.
In short, under the current new medical reform situation, “difficult in seeing a doctor and expensive to see a doctor†is not only a problem in the mechanism and system, but also a major livelihood issue that concerns the health of the people. Being treated as a doctor is one of the basic requirements of human beings and one of the most basic responsibilities of society. The medical insurance system is the people's livelihood project. It is incumbent responsibility to manage and use health insurance costs. Social security card real-time settlement is the challenge that the hospital will face. The payment method and settlement method of medical insurance is the core content of medical insurance management. Any settlement method is not a panacea, and it will have its own defects and weaknesses. This requires the We continue to explore and boldly innovate to make medical insurance management and hospital management embark on a path of healthy, harmonious and sustainable development, and to promote hospitals to become people-oriented service-oriented and scientific development learning organizations.
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