Since 2009, some hospitals in Beijing have begun to implement the real-time settlement pilot promotion of patients with social security cards in the hospital outpatient window. By 2010, all types of hospitals in Beijing have been fully applied. This kind of "card-based medical treatment, real-time settlement" has changed the past patients to pay medical expenses in full in outpatient clinics, and then hand-held various types of bills (such as prescriptions, receipts, test sheets, etc.) to the social security center for centralized processing. The inconvenience of reimbursement is directly reimbursed by the medical insurance institution, which greatly facilitates the patient's medical treatment and the pressure on the funds, so that the people can truly feel the convenience and benefits of the policy.
From the perspective of hospital management, we analyze the real-time settlement of medical insurance. We found that the main process of this work is as follows: The hospital needs to embed the business components provided by the medical insurance institution in the software related to the outpatient registration (such as HIS software). When the patient seeks medical treatment and costs are incurred. Through the business component to decompose the patient's expenses and print the bill (except the registration fee), the patient only needs to pay the self-pay part within the scope of the medical insurance and the self-pay part outside the scope of the medical insurance, and the remaining part that needs to be paid by the medical insurance fund is approved by the medical insurance institution after passing the examination. Pay for the hospital.
According to the above process, this work must reform and innovate the original management system, working mode and business process of the hospital. It not only makes the hospital information construction face new challenges, but also puts forward new requirements for the hospital financial management. At the same time, as an important benefit project of the Beijing Municipal Government, it occupies the direct economic burden of patients and relieves the relationship between doctors and patients. Play a decisive role. Therefore, while the hospital pays great attention to this work, it should carefully sort out the problems and difficulties in the initial stage of the real-time settlement of social security cards, and propose solutions and suggestions to make the work at the same time as Huimin. It can also guarantee the normal operation of the hospital and its own development, so that the people, the government and the hospital can achieve a harmonious and win-win situation and promote the healthy development of Beijing's medical and health undertakings.
First, the problems and difficulties encountered by the hospital in promoting the real-time settlement management of medical insurance
1. The hospital toll system is difficult to interface with the medical insurance system. The first problem faced by hospitals in implementing real-time settlement of medical maintenance cards 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 realized diversified information software such as charging system (HIS system), financial management system, material system and fixed asset system. The medical insurance system required by the medical insurance real-time settlement is provided by the medical insurance institution and needs to be effectively connected with the hospital outpatient charging system. The current difficulties faced by hospital charging systems are: because the relevant government departments do not provide a unified hospital charging system or uniform technical specifications, resulting in the purchase and development of hospitals themselves, so the level of hospital charging systems is uneven, need to be one by one Connect with the software of the medical insurance center. Only when the basic information of the patient's social security card number, name, gender, etc. in the hospital charging system is strictly consistent, can it be uploaded to the medical insurance system, and the current situation of the hospital charging system makes it difficult to connect with the medical insurance system, and the information inconsistency is very likely to occur, affecting Medicare settlement efficiency increases the risk of medical insurance refusal.
2. While the hospital is responsible for increasing the amount of funds for medical insurance, the risk of funds has also increased significantly. Different from the prepaid payment settlement method of the original outpatient medical insurance patients, the patient who settles the card in real time only needs to pay the card to pay part of the personal payment, and the rest of the expenses will be settled directly by the hospital and settled with the medical insurance department. After the medical insurance center has checked and approved the cost data uploaded by the hospital, it will return it to the hospital for payment. If the unqualified data is reviewed for the fee paid, the hospital will need to re-upload or be directly charged. The change of this settlement mode has caused two difficulties for the hospital: Firstly, because the real-time settlement of the card is a large amount of funds from the hospital, and the time for medical insurance payment cannot be effectively guaranteed, this greatly increases the pressure on the hospital's capital turnover. However, the huge pressure on the hospital's working capital may lead to triangular debts between hospitals, medical insurance and pharmaceutical companies, affecting the normal development of the hospital. Secondly, while the hospital bears huge financial pressure, the risk of being refused payment by the medical insurance center is also transferred from the patient to the hospital. According to the relevant requirements, only the outpatient medical service of the hospital can achieve reasonable medical treatment, reasonable medication, and reasonable expenses. The medical insurance center refused to pay, which made the hospital bear huge regulations and supervised medical behaviors, which undoubtedly increased the risk of hospitals being refused payment, and also increased the difficulty of reconciliation and recovery of medical insurance returns.
3. For the real-time settlement of medical insurance, financial personnel face new challenges. The implementation of card real-time settlement increases the time for the card to be swiped and the cost is decomposed in the original waiting time. In order to reduce the patient waiting time, the financial department needs to add more charging windows at the toll booth, and also needs to complete the establishment of the outpatient medical payment. Detailed accounts, data uploading, collation papers, checking medical insurance returns, refining accounting, changing account processing and other tasks. This requires that both the window charger and the account checker should be familiar with the medical insurance policy. For example, the patient’s doubts about the inconsistency between the refund and the current payment of the cash will cause the insured to stay in the window. A series of questions such as the waiting time for enquiry, registration and payment, and the disorder of payment, may lead to contradictions between doctors and patients. Therefore, how to solve the problem of charging personnel and the division of work to do the above work is a work challenge faced by financial personnel.
Second, the solution to the problem and countermeasures
1. 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 from different companies to meet their own development needs, most HIS systems have problems such as repeated development, lack of unified industry standards, and immature technology, so the settlement method changes and the system transformation process In the hospitals, hospitals still need to invest a large number of people, materials, and wealth to improve the system transformation. From the perspective of resource allocation in the entire health industry, the resources of various hospitals cannot be rationally and effectively allocated, and medical waste is happening. This phenomenon is even more pronounced in the real-time settlement of HIS for medical insurance. For example, every hospital has to pay for the software development company to transform.
It is recommended that the hospital industry department should establish a unified and mandatory HIS system access standard in the Beijing area according to the hospital level or specialist type, or uniformly purchase related software, and gradually expand to the logistics system and fixed asset system. And more than a variety of information. This will not only make the internal data integration and analysis of the health system more effective, but also help the health industry as a whole to connect with medical insurance or other industries. Specifically, we can learn from the unified status of financial related software in Beijing hospitals: Beijing municipalities and district-level hospitals at all levels have been uniformly procured by the Health Bureau in 1999 and require hospitals to use the gold abacus financial software for accounting processing. In real time today, regular collection of all financial data and major upgrade adjustments can be done efficiently under the overall planning of the Health Bureau. On this basis, the municipal hospitals have realized the unification of related software such as cost accounting and budget management.
2. The hospital should improve internal management and strengthen external coordination. After the hospital implemented the real-time settlement of the medical insurance card, the original limited capital turnover was even more stretched, and the financial risk brought by the medical insurance refusal was more obvious than before. Therefore, the amount of funds advanced by the hospital is large, the time is too long, and the medical expenses of patients cannot be recovered in time to become a difficult point and key point in the medical insurance work. It is 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 promote internal management. First of all, medical staff should strictly implement the medical insurance system and improve the quality management of hospitals. It is necessary for the majority of medical personnel to increase the propaganda of medical insurance policies, so that the medical insurance system can form behavioral norms and strengthen medical ethics education among medical personnel, emphasizing rational use of drugs and treatment due to illness, eliminating the need to open large prescriptions and human feelings, and try not to use valuable drugs. . Strictly take care of the medical insurance system, so as to effectively cut off the medical insurance due to unreasonable medical behavior and refuse to pay. Second, the accuracy of medical insurance settlement and information transmission should be improved. The real-time settlement of medical insurance is the specific implementation of the medical insurance policy in the hospital. The clearing personnel should effectively intercept the wrong information, blacklist, and other diseases outside the medical insurance policy, so that the settlement is accurate and timely uploaded to the social security center as required, thereby improving Medical insurance return speed.
From the outside, it is an objective and practical problem for the hospital to occupy a large amount of funds after real-time settlement, and it will inevitably affect the use of funds and the development of the hospital. Under the existing medical insurance system, the problem of large capital occupation is difficult to solve effectively by individual hospitals. Therefore, it is necessary for the hospitals to actively coordinate with the health authorities to promote effective communication between the health authorities and the medical insurance departments, and to protect the hospitals from the policy. healthy growth. The ideas that can be borrowed are as follows: The government can consider the combination of medical insurance and reimbursement from the current post-payment system to the pre-paid and post-payment systems. That is, the medical insurance institution sets the basic amount according to the medical insurance settlement amount of the first two years of each hospital, and pays it to the hospital in advance according to a certain proportion. The remaining part can be gradually paid according to the current situation according to the current situation. This method can effectively alleviate the problem of financial stress in the hospital, and bring motivation to the hospital to improve the quality of service and implement the medical insurance policy.
3. Strengthen the training of financial personnel and improve the level of medical insurance. Personnel training is a long-term work involving people, finances, materials, etc. 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, in batches and stages, on the management and operation level of the financial department. staff training. In accordance with the implementation of real-time settlement work requirements, combined with the real-time settlement manual and the relevant departments of the higher authorities on medical insurance, as training materials. The relevant personnel of the hospital and the engineers of the software company shall undertake the personnel training tasks, explain in detail the specific problems, and simulate the actual operation. The outpatient and toll collection personnel must pass the actual level test of the relevant software. In addition, in addition to proficient in medical insurance policies and related software, the settlement staff should also understand the proportion of commonly used A and B drugs, inspection tests and high-value consumables at their own expense, so as to be proficient in the decomposition and entry of medical insurance costs, to ensure the accuracy of relevant information. And efficient.
In short, under the current situation of new medical reform, "difficult to see a doctor, expensive to see a doctor" is not only a problem within the mechanism and system, but a major livelihood issue concerning the health of the people. Having 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 a livelihood project. It is an unshirkable responsibility to manage and use medical insurance. The real-time settlement of social security card is a challenge that hospitals will face. The payment method and settlement method of medical insurance is the core content of medical insurance management. Any settlement method is not omnipotent, and there will be its own defects and weaknesses. We continue to explore and boldly innovate, so that medical insurance management and hospital management are on the path of healthy, harmonious and sustainable development, and promote the hospital to move towards a people-oriented service-oriented and scientific development learning organization.
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