Risk analysis of drug-related medical insurance claim denials in healthcare institutions and exploration of phar-macist-led intervention model
- VernacularTitle:医疗机构药品医保拒付风险分析及药师主导的干预模式探索
- Author:
Xiaolan WANG
1
;
Jie PAN
1
;
Yi GE
1
;
Bo LYU
1
;
Qian ZHOU
2
;
Aiming SHI
1
Author Information
1. Dept. of Pharmacy，The Second Affiliated Hospital of Soochow University，Jiangsu Suzhou 215000，China
2. Medical Insurance Office，The Second Affiliated Hospital of Soochow University，Jiangsu Suzhou 215000，China
- Publication Type:Journal Article
- Keywords:
risk matrix;
insurance claim denial;
pharmaceutical intervention;
pre-authorization of prescriptions
- From:
China Pharmacy
2026;37(14):1832-1837
- CountryChina
- Language:Chinese
-
Abstract:
OBJECTIVE To develop a pharmacist-led intervention model for reducing drug-related medical insurance claim denial risks， so as to provide practical references for healthcare institutions in fulfilling their primary responsibility for medical insurance fund supervision. METHODS A risk matrix method was employed by the pharmacists to assess the risks associated with drug‑related medical insurance claim rejections in our hospital during 2024. Intervention measures were developed targeting high‑risk factors (including inappropriate indications for medical insurance coverage, exceeding the covered treatment course, and inappropriateness of gender and age) from three dimensions, namely organizational structure, technical prevention and control, and closed‑loop management. Changes in drug‑related claim rejection data were compared between 2024 (pre‑intervention) and 2025 (post‑intervention), and the interception effect of the pre‑prescription review system was evaluated after the intervention. RESULTS After the intervention, the total amount of drug‑related medical insurance claim rejections in our hospital was reduced by 57.24% compared with that before the intervention, and the number of rejected items decreased from 10 108 to 2 892. Specifically, the number of rejected items due to inappropriate indications, exceeded treatment course, inappropriate gender, and inappropriate age was reduced by 70.94%, 74.26%, 83.86%, and 96.70%, respectively. Throughout the year following the intervention, a total of 5.605 yuan million in outpatient prescription drug amounts and 4.683 million yuan in inpatient medication order amounts that did not meet the insurance‑limited payment requirements were intercepted by the pre‑prescription review system. The proportion of drug‑related claim rejection amount to the total medical service claim rejection amount of our hospital decreased to 19.7%. CONCLUSIONS The pharmacist-led multi-department collaborative， technical prevention and control， and dynamic optimization integrated full-process intervention model is highly operable and has significant practical effects. It has important promotion value in reducing drug-related medical insurance claim denial risks.
