First, the basic requirements of medical insurance work
1. Learn, publicize and implement the medical insurance policy, and abide by the rules and regulations and operating procedures of the hospital.
2. Standardize medical service behavior, improve medical quality and ensure medical safety.
3. Reasonable examination, reasonable treatment, rational drug use and reasonable charges.
4. Clarify the medical insurance responsibility and implement the regulatory responsibility.
5. Implement daily dynamic supervision and regular inspection and assessment of diagnosis and treatment work, and advocate self-examination and self-correction, and self-management.
6. Publish the telephone number of complaints, distribute questionnaires, timely check complaints and problems reflected, and give feedback on handling opinions.
7. Continuously improve the medical environment, improve medical technology, control medical expenses, and better serve insured patients.
2. Medical process management
1. Adhere to the "patient-centered" principle and serve the insured patients enthusiastically, conveniently and thoughtfully.
2. The attending doctor and the doctor in charge of the ward should ask whether the patient participates in medical insurance; Medical insurance managers and ward reception nurses are responsible for the identification of insured patients, so that people, certificates and cards are consistent and prevent imposters.
3. Actively publicize and introduce relevant medical insurance policies and regulations to insured patients, and respect patients' right to choose independently.
4. Strictly implement the principle of "treating due to illness", and conduct reasonable examination, treatment and medication.
5. Go through the discharge formalities for insured patients who meet the discharge conditions in time, and do not stay in bed. Because of chronic diseases need long-term hospitalization, must be settled once every three months (by the competent doctor issued a summary of hospitalization and proof of continued hospitalization), and reported to the medical insurance department for registration, to the social security agency center for continued hospitalization procedures.
6. Conduct objective, accurate and timely accounting and settlement of discharge expenses for all kinds of diagnosis and treatment project expenses (after the discharge medical records of insured patients are sent to the medical insurance handling office, all records of diagnosis and treatment expenses will be stopped, and the handling personnel will complete the settlement of total expenses on the same day).
Three. Implementation and management of diagnosis and treatment
1. First-visit physician responsibility system shall be implemented, and outpatient physicians shall carry out relevant examinations according to the condition and basically make a definite diagnosis (except for acute and critical diseases).
2. Strictly master the hospitalization standard, implement the basic medical insurance "Catalogue of Diseases for Overall Payment of Hospitalization Medical Insurance", and do not admit patients who do not meet the hospitalization conditions or decompose them into hospitals.
3. Ward doctors in charge and superior doctors should check and treat inpatients in time according to relevant regulations, and record all drugs checked, treated and used on the doctor's advice list.
4 to avoid unnecessary repeated inspection, make full use of the valuable inspection results of other medical institutions above the second level in this province.
5 as far as possible, use the drugs listed in the basic medical insurance drug list and the medical treatment projects or service facilities within the scope of basic medical insurance payment. For drugs, treatment items or service facilities that need to be paid at their own expense or within the scope of reimbursement but need to be paid at their own expense, before they are included in the overall plan, they should be made clear to the patients or their families in advance, and their opinions should be solicited. When necessary, they should sign a self-payment agreement with the medical insurance patients, and strictly control the self-payment ratio not to exceed 10%.
6. Require specialized treatment for special diseases, establish a normal referral system, and make a clear diagnosis within three days of admission. Non-undergraduate students who mainly treat diseases or need to switch to professional treatment due to illness should first organize consultations, and the director of the department should put forward referral opinions and report them to the medical insurance department for registration. When it is necessary to transfer, it shall be signed by the dean in charge, registered and sealed by the medical insurance department, and transferred to the social security handling center.
Four. Drug and drug administration
1. The pharmacy department should provide all clinical departments with the names, dosages and prices of drugs in the Catalogue of Medicines for Basic Medical Insurance purchased by our hospital that year, so as to ensure that the drug preparation rate of Class A drugs is above 85% and that of Class B drugs is above 70%.
2. Choose Class A drugs in the basic medical insurance drug list according to the illness, and choose varieties with good curative effect and lower price among similar drugs; If you need to use restricted drugs, you must fill in the Application Form for the Use of Drugs with Restricted Payment Scope and Rescue Drugs, which shall be signed by the department director, registered by the medical insurance department, and approved by the competent dean before use (rescue first, and go through the examination and approval procedures within one day after use). Do not apply for examination and approval, at their own expense.
3. The treatment of drugs should focus on the main diseases (first diagnosis) and give consideration to the secondary diseases or complications. All drugs should be prescribed by the competent physician, and temporarily prescribed by the doctor on duty under special circumstances. Each ward should arrange special personnel to take drugs.
4. Insured patients who are cured and discharged from hospital do not take medicine, and those who need to take medicine when their chronic diseases get better and discharged from hospital generally do not exceed two varieties for ten days.
Verb (abbreviation of verb) management of special examination and special treatment
1. If the diagnosis cannot be confirmed by routine examination, and special examination or treatment (single cost 1000 yuan or more) is needed, the approval form for special materials and special examination shall be filled in by the attending physician or above, signed by the department director, registered and sealed by the medical insurance department, signed by the competent director, and implemented after being examined and approved by the municipal social security handling center.
2. Due to illness, it is necessary to install artificial organs and use special materials. First of all, we must choose domestic materials. When there are no domestic products or contraindications, joint ventures or imported materials can be considered, but patients and their families cannot be induced to use imported products.
Supervision and evaluation of intransitive verbs
1. The director of the clinical department is responsible for guiding and supervising the diagnosis and treatment work and cost control of medical insurance patients in this department, that is, he is responsible for the medical insurance management of undergraduates, organizing self-examination and self-correction of undergraduates, and constantly standardizing medical behavior.
2. The medical insurance management department is responsible for the daily supervision of the whole process of medical insurance patients in the whole hospital, and contact the department director or relevant personnel in time when finding the tendentiousness problem, and properly solve the existing problems; Check the implementation of the Catalogue of Diseases for Overall Payment of Medical Insurance, the Catalogue of Drugs for Basic Medical Insurance in Shaanxi Province, the diagnosis and treatment items or service facilities within the scope of payment of basic medical insurance, and the total expenses and expenses in the diagnosis and treatment of medical insurance patients in various departments every month, and summarize and feedback the inspection results.
3. According to the contents and requirements of "Interim Measures for Annual Assessment of Designated Medical Institutions in * * City", the medical insurance management department cooperates with the hospital quality management committee to organize a comprehensive assessment of hospital medical insurance work every six months, and quantify the score.
Seven. Reward and punishment measures
1. The daily medical insurance management of the department is in place, and there is no record of violation of medical insurance policies and regulations. The relevant medical service quality assessment results are excellent in the medical insurance work assessment at all levels. The hospital gives the department a one-time reward every six months.
2. Medical insurance patients who have caused complaints or disputes due to improper service attitude or service measures shall be dealt with according to the relevant provisions of the Measures for the Administration of Hospitals after investigation.
3. Due to unreasonable examination, treatment and drug use, the cost exceeds the average cost of the department 10%, and the department bears 30% of the cost; Exceeding the department average cost 10%-20% and exceeding the cost by 70%; If it exceeds the average cost of the department by more than 20%, the department that exceeds the cost shall bear all the expenses.
4. Medical insurance patients need self-funded diagnosis and treatment projects and drugs that must be used. They should inform the patients or their families in advance, but they didn't inform them. All expenses that have not been signed at their own expense should be borne by the bookkeeping doctor through consultation with the patients.
5. Non-competent doctors of medical insurance patients can't prescribe drugs for more than one day, and pharmacists should take good care of drugs. In violation of the provisions, the drug expenses shall be borne by the prescriber, pharmacy personnel and drug personnel in consultation with the patient's family.