Construction and empirical study of a hierarchical medical insurance intelligent audit system
10.3969/j.issn.1671-332X.2025.07.027
- VernacularTitle:基于分层架构的医保智能审核系统构建与实证研究
- Author:
Pengyang ZHOU
1
;
Xuhong PU
;
Lili LIU
Author Information
1. 甘肃省中医院 甘肃兰州 730050
- Publication Type:Journal Article
- Keywords:
Medical insurance fund;
Intelligent audit of medical insurance;
Cost control
- From:
Modern Hospital
2025;25(7):1088-1090,1095
- CountryChina
- Language:Chinese
-
Abstract:
Objective To dynamically supervise medical insurance diagnosis and treatment behaviors through informa-tion technology,prevent compliance risks,and improve the efficiency of hospital medical insurance fund management.Methods Taking Gansu Provincial Hospital of Traditional Chinese Medicine as the research object,a hierarchical medical insurance in-telligent audit system was constructed,and core functional modules were designed to achieve full-process supervision.Based on system operation data,the audit efficiency,standardization of diagnosis and treatment behaviors,and cost control effects were compared and analyzed.Results After the system was launched,the time required for a single audit decreased from 5 minutes to 0.6 minutes,with an 88％improvement in processing efficiency.The average hospitalization cost for provincial residents de-creased by 16.33％year-on-year,and overall expenditures decreased by 16.34％.Billing loopholes and unreasonable charging behaviors were corrected.Conclusion The medical insurance intelligent audit system can effectively enhance supervision effi-ciency,standardize diagnosis and treatment behaviors,and control unreasonable cost growth.Additionally,it is recommended to further improve the intelligent supervision system through multi-dimensional policy education,deep integration with clinical sys-tems,and algorithm optimization.
