Construction and application of an intelligent insurance medication audit system based on pre-auditor system
10.3760/cma.j.cn111325-20231218-00410
- VernacularTitle:基于前置审方系统的医保用药智能审核系统构建及应用
- Author:
Xiaoyan WU
1
;
Haixia ZHANG
;
Mian ZHAO
;
Xiaojie BIAN
;
Jie PENG
;
Hao ZHOU
;
Bin ZHANG
;
Weihong GE
Author Information
1. 南京大学医学院附属鼓楼医院药学部，南京 210008
- Keywords:
Drug utilization review;
Medical insurance medication;
Intelligent audit;
Pre-audit;
Medical insurance fund
- From:
Chinese Journal of Hospital Administration
2024;40(7):541-546
- CountryChina
- Language:Chinese
-
Abstract:
The establishment of an intelligent audit system for hospital medical insurance is crucial for standardizing irrational practices and curbing the unwarranted escalation of medical insurance costs. A tertiary hospital has developed comprehensive prescription review rules in terms of indications, nutritional risk assessments, pain score evaluations, drug sensitivity test results, and target patient populations. When using medical insurance funds for settlement, both systematic and manual reviews are conducted, and three-level intervention measures such as " prompt, review, and interception" are implemented based on prescription issues. After the system was put into use, the hospital′s in-process information system supervision mode shifted from the previous focus on prompts to focus on audits. The medical insurance intelligent audit system provided timely prompts and interventions, and the number of unreasonable medical insurance prescriptions and deductions from medical insurance sampling prescriptions significantly decreased ( P<0.001), while the number of medical insurance medication prescription audits increased ( P<0.001). The application of the intelligent medical insurance medication audit system has improved the efficiency of prescription auditing and ensured the rationality of the use of medical insurance funds.
