Comparative Study on Intelligent Audit and Monitoring Repository of Focused Audit Violations under DRG Payment
- VernacularTitle:DRG付费下重点稽核违规行为智能审核和监控规则库比较研究
- Author:
Zhiguo ZHANG
1
;
Qingqin LIU
;
Chen XIANG
;
Xiangping LIU
Author Information
1. 华中科技大学同济医学院医药卫生管理学院 湖北武汉 430030;湖北省卫生技术评估研究中心 湖北武汉 430030
- Keywords:
DRG;
intelligent audit system;
monitoring;
rule repository;
health insurance fund
- From:
Chinese Hospital Management
2024;44(6):77-82
- CountryChina
- Language:Chinese
-
Abstract:
Objective Comparative analysis of rule categories,key audit behaviors,and the degree of correspon-dence between rules and behaviors through intelligent auditing of key audit violations and monitoring of the rule base.To provide reference for the improvement of intelligent audit and monitoring rule library for key audit violations under DRG payment in medical insurance fund.Methods Searching and collecting policy documents such as DRG payment management methods issued by local health insurance bureaus from May 20,2019 to December 31,2023 and the literature related to DRG payment smart audit monitoring rules in the database,and targeting the rules therein that are related to the focus on auditing irregularities under the DRG payment.Literature analysis and comparative analysis were used to summarize and analyze the rules related to key audit violations under DRG payment.Results The intelli-gent audit rules for key audit violations under DRG payment can be divided into two major categories:logical judg-ment and parameter index,and the degree of correspondence between audit rules and key audit behaviors varies.Conclusion(1)Unify the key audit rules nationwide to ensure the universality and comprehensiveness of the rules;(2)Deepen the current situation of regional illegal activities and strengthen local characteristics;(3)Improve the quality of logical judgment rules and increase the quantity of parameter indicator rules;(4)Strengthen scientific re-search on new types of violations,and establish more targeted regulatory rules.
