武汉市某医院开展商业健康保险直付服务的实践及思考

摘要

Commercial health insurance institutions cooperating with medical institutions to carry out the "direct-billing service"is an in-ternational method for commercial health insurance claims.This article analyzed the practice of a certain hospital in Wuhan carrying out the "di-rect-billing service"as an example, discussed the causes of restriction in medical institutions'execution of "direct-billing service", which are small-scale commercial health insurance and hospital cost control.Problems occurred while attempting to carry out the service are summarized. For instance, the insurance company refused to pay medical expenses, the medical risk is excessive, the hospital cost increased, it violates the e-qualization of essential healthcare services.This paper proposes some suggestions on medical institutions'execution of "direct-billing service", such as reinforcing risk control, participating in the management of"big data"in the healthcare industry, reforming hospital HIS system with com-mercial insurance institutions, and adjusting the price system of "direct-billing service".%医疗机构与商业健康保险机构开展直付服务合作，是国际通用的商业健康保险理赔方式。本文通过分析武汉市某医院开展直付服务的实践，探讨当前医疗机构开展直付服务受限的原因：商业健康保险规模过小；医院成本控制总结运行中遇到的问题，即存在医疗费用拒付和过度医疗的风险、增加医疗机构成本、有违医疗服务均等化原则，并就医院开展直付服务提出建议：加强风险管控、参与“大数据”健康管理、联合商保机构改造HIS系统、调整直付服务价格体系。