Practice of medical insurance management for ambulatory surgery from the perspective of DRG/DIP
10.3969/j.issn.1671-332X.2025.07.020
- VernacularTitle:DRG/DIP视角下日间手术医保管理实践
- Author:
Lei ZHANG
1
;
Huiming LI
1
;
Jie RONG
1
Author Information
1. 天津市人民医院//南开大学第一附属医院 天津 300121
- Publication Type:Journal Article
- Keywords:
DRG/DIP payment;
Ambulatory surgery;
Medical insurance compliance;
Management strategy
- From:
Modern Hospital
2025;25(7):1056-1060
- CountryChina
- Language:Chinese
-
Abstract:
Objective With the comprehensive implementation of Diagnosis-Related Groups(DRG)and Diagnosis-In-tervention Packet(DIP)payment reforms,ambulatory surgery has been widely adopted in clinical practice due to its efficiency and cost-effectiveness.However,medical insurance compliance issues have become increasingly prominent during management processes.Standardizing ambulatory surgery management and ensuring the security of medical insurance funds have grown in im-portance.Methods Based on the current status of ambulatory surgery medical insurance policies in Tianjin,this study analyzes common compliance issues under DRG/DIP payment systems,explores their causes,and proposes targeted management strate-gies.Results Tianjin currently has 786 ambulatory surgery procedures,with orthopedics being the most common specialty,fol-lowed by ophthalmology,urology,and general surgery.From 2020 to 2024,the sample hospital completed 12,705 ambulatory surgery cases,with a significant increase in 2024.In 2020,the most frequent procedure was circumcision,while in 2024,it was colonoscopic polypectomy.Under DRG/DIP payment systems,common medical insurance compliance issues include upeoding,split hospitalization,excessive treatment,cost shifting,and undertreatment.Conclusion Healthcare and medical insurance sys-tems should collaborate to implement targeted management strategies.These include strengthening hospital medical record and coding management,improving medical quality control,refining medical insurance supervision mechanisms and payment stand-ards,and establishing a multi-stakeholder collaborative oversight system.These measures aim to standardize ambulatory surgery management,safeguard medical insurance funds,and promote the healthy development of the healthcare industry.
