无锡市医保智能监控体系建设的实践探索

摘要

In 2012, the constructing of medical insurance intelligent monitoring system was initiated in Wuxi. Since then, by continuously innovating monitor rules, enriching monitor methods, and improving and standardizing basic data, it has formed multi-dimension medical insurance intelligent monitor on two-designated institutions, physicians and the insured persons before, during, and after they provide medical service. In 2015, it has recovered 23 million yuans of wrong cost, and prevented indirectly 1 billion cost. The growth rate of health care cost has been reduced from 20%to 8%. In 2016, the constant increase of medical cost over years is initially decreased, showing significant effect of insurance monitor.%无锡市于2012年启动医保智能监控系统建设，四年来，通过不断创新监控规则，丰富监控手段，注重基础数据的完善和规范，构建出两定机构、医生和参保人等多维度，具备事前、事中和事后三个延伸端口的医保智能监控体系。2015年，追回医保违规费用2300万元，可统计的间接遏制医疗费用近1亿元，医疗费用从历年20%以上的增幅控制到8%以内，且2016年实现了历年医疗费用持续高涨后的首次下降，监控效果显著。