Optimization strategies for quality control of medical insurance payment lists driven by DRG assign-ment analysis
10.3969/j.issn.1671-332X.2025.04.017
- VernacularTitle:DRG入组分析驱动的医保结算清单质量控制优化策略
- Author:
Xueli YAN
1
;
Huang ZUO
1
;
Deying KONG
1
Author Information
1. 西安交通大学第一附属医院 陕西西安 710061
- Publication Type:Journal Article
- Keywords:
Medical insurance payment lists;
Quality control;
Case;
DRG
- From:
Modern Hospital
2025;25(4):556-559
- CountryChina
- Language:Chinese
-
Abstract:
Background Medical insurance payment lists are important evidence for health insurance settlement and the basis for reasonable DRG payments.However,there are currently many quality control defects that affect the correct DRG assign-ment and the reasonable payment of medical insurance funds.Methods This paper adopts a case analysis approach,combined with clinical knowledge,coding specifications,and mapping relationships,to analyze the quality defects of the current medical insurance payment lists in the hospital.Results This paper proposes refined management strategies and suggestions,including strengthening information construction,improving the professional level of quality control personnel,improving the data quality of the front-end medical record homepage,optimizing the mapping relationship of the dictionary library,carrying out clinical com-munication and training,and establishing a closed-loop quality control system for medical insurance payment lists.These strate-gies effectively improve the data quality of medical insurance payment lists and the accuracy of DRG assignment.Conclusion The management of medical insurance payment lists involves multiple links,departments,and technologies and needs continuous improvement to support hospital refined management.
