摘要目的 建立覆盖事前提醒、事中质控、事后监管的全过程医保基金闭环管理体系，保证医保基金使用的合理性，
提升医院精细化管理水平。方法 根据制度、法规全面梳理审计规则，建立审计知识库，利用“医保管理+大数据”智能
化平台，通过住院医嘱违规提醒、在院患者每日审计、患者转科/出院审计拦截、门诊病历违规提醒等多种审计方式在患
者就诊期间进行动态审计，对历史数据进行大数据审计和医保指标分析，定位医保管理薄弱环节，构建全方位、全流程
医保基金智能管理体系。结果 应用医保合理收费审计系统后，我院患者药占比（27.41%±3.38% vs. 29.39%±2.87%）、
耗占比（18.00%±1.60% vs. 21.38%±2.00%）、辅助用药收入占比（0.33%±0.26% vs. 0.43%±0.29%）、抗菌药物使
用率（34.93±0.83% vs. 40.43%±2.84%）、抗菌药物使用强度（37.13%±3.21% vs. 40.43%±2.84%）、门诊患者次
均费用[（150.03±6.73 ）元 vs.（ 180.25±5.95）元]相较于应用前显著下降，且差异有统计学意义（P<0.05）；基本
用药收入占比较应用前升高（31.69%±2.74% vs. 30.49%±3.57%，P=0.030）；出院患者次均费用较应用前有所下降
[（17607.20±8060.41）元 vs. （20942.33±9991.38）元]，但差异无统计学意义（P=0.050）。结论 基于“医保管理+大数
据”的合理收费审计系统，提升了医保基金监控效率，实现了医保精细化、动态化、现代化管理变革。
Abstract：Objective To establish a closed-loop management system of medical insurance fund covering the whole process of prereminder,
in-process quality control and post-supervision, so as to ensure the rational use of medical insurance fund and improve the
level of the hospital’s delicacy management. Methods The audit rules were comprehensively sorted out according to the system and
regulations, the audit knowledge base was established. And the intelligent platform of “medical insurance management+big data”
was used to conduct dynamic audit during the treatment period of patients through a variety of audit methods, such as reminding of
medical orders’ violations, daily audit of in-hospital patients, interception of patient transfer/discharge audit, reminding of outpatient
medical records’ violations. And the big data audit and medical insurance indicators analysis on historical data was conducted,
the weak links in medical insurance management was located, and then an all-round and whole process intelligent management
system for medical insurance funds was built. Results After applying the medical insurance reasonable charge audit system, in our
hospital, the proportion of drugs (27.41%±3.38% vs. 29.39%±2.87%), the proportion of medical consumables (18.00%±1.60% vs.
21.38%±2.00%), the proportion of income from adjuvant drugs (0.33%±0.26% vs. 0.43%±0.29%), the usage rate of antibiotics
(34.93%±0.83% vs. 40.43%±2.84%), the usage intensity of antibiotic (37.13%±3.21% vs. 40.43%±2.84%), and the average cost
per outpatient visit [(150.03±6.73) yuan vs. (180.25±5.95) yuan] were significantly decreased compared with before application,
and the difference was statistically significant (P<0.05). The proportion of income from essential drugs was higher than before
(31.69%±2.74% vs. 30.49%±3.57%, P=0.030). The average cost of per discharged patients was decreased [(17607.20±8060.41)
yuan vs. (20942.33±9991.38) yuan], but the difference was not statistically significant (P=0.050). Conclusion The reasonable
charge audit system based on “medical insurance management+big data” has improved the monitoring efficiency of medical
insurance fund and realized the delicacy, dynamic and modern management reform of medical insurance.
王泽阳a，孙婕a，段彦辉a，刘瑜b，李立杰a，张玉洁a. 医保合理收费审计系统的设计与应用[J]. 中国医疗设备, 2023, 38(6): 101-107.
WANG Zeyanga, SUN Jiea, DUAN Yanhuia, LIU Yub, LI Lijiea, ZHANG Yujiea. Design and Application of Medical Insurance Reasonable Charge Audit System. China Medical Devices, 2023, 38(6): 101-107.
