CN114493894A - 使用医保审核规则模型进行医疗行为监控的方法 - Google Patents
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Abstract
本发明涉及使用医保审核规则模型进行医疗行为监控的方法，参考临床路径的思路，结合各类疾病指南及专家共识，以每个诊断病例的必要诊疗项目为依据，建立最小单位模块；将所有最小单位模块组合，构建规则模型；向规则模型中导入参保人病案，判断病案中诊断是否有必要诊疗项目缺失，若有，则抓取违规并提示，并进行下一步，若无，则判断该病案符合判断标准；人工审核。建立最小单位模块，利用信息化技术手段，将所有最小单位模块组合为规则模型，利用规则模型将违反医保规定的医疗行为筛选出来，并依据临床医学路径、诊疗指南以及医保政策判断违规类型，从而对医保收费单据形成有效的智能审核，以确保医疗诊疗服务质量。
Description
技术领域
本发明涉及医疗管理领域，具体涉及一种使用医保审核规则模型进行医疗行为监控的方法。
背景技术
医保覆盖人群数量不断增加，患者对医疗的依赖性和就医频次增加，加上医疗机构的利益驱使，过度诊断、过度治疗、不合理手术和违规操作不可避免，使得基金的支出日益扩大，多地医保面临基金穿底的风险，进而亟需推进医疗行为监控服务，以较少违规操作。
发明内容
本发明所要解决的技术问题是提供一种使用医保审核规则模型进行医疗行为监控的方法，以克服上述现有技术中的不足。
本发明解决上述技术问题的技术方案如下：
一种使用医保审核规则模型进行医疗行为监控的方法，包括如下步骤：
S1、参考临床路径的思路，结合各类疾病指南及专家共识，以每个诊断病例的必要诊疗项目为依据，建立最小单位模块；
S2、将所有最小单位模块组合，构建规则模型；
S3、向规则模型中导入参保人病案，判断病案中诊断是否有必要诊疗项目缺失，若有，则抓取违规并提示，并进行下一步，若无，则判断该病案符合判断标准；
S4、人工审核。
在上述技术方案的基础上，发明还可以做如下改进。
进一步，必要诊疗项目包括但不限于：手术、检查、检验、药品项目。
进一步，每个病例的诊断分为主诊断和次诊断，其中，主诊断对应的必要诊疗项目与次诊断对应的必要诊疗项目不同。
进一步，在判断次诊断是否低码高编时，去除该诊断，重调分组，比较两次分组是否相同，并判断组间差价，若两次分组差价大于预设偏差值，且含有必要项未做，则该病案可能存在低码高编。
进一步，规则模型根据数据情况及地区特异性调整松紧度。
本发明的有益效果是：以每个诊断病例的必要诊疗项目为依据，建立最小单位模块，利用信息化技术手段，将所有最小单位模块组合为规则模型，然后利用规则模型将违反医保规定的医疗行为筛选出来，并依据临床医学路径、诊疗指南以及医保政策判断违规类型，从而对医保收费单据形成有效的智能审核，以确保医疗诊疗服务质量。
附图说明
图1为发明所述使用医保审核规则模型进行医疗行为监控的方法的流程图。
具体实施方式
以下结合附图对发明的原理和特征进行描述，所举实例只用于解释发明，并非用于限定发明的范围。
实施例1
如图1所示，一种使用医保审核规则模型进行医疗行为监控的方法，包括如下步骤：
S1、参考临床路径的思路，结合各类疾病指南及专家共识，以每个诊断病例的必要诊疗项目为依据，建立最小单位模块；
S2、将所有最小单位模块组合，构建规则模型，可作为判断疾病与治疗是否符合的判断标准，特异性、准确性较高；
S3、向规则模型中导入参保人病案，判断病案中诊断是否有必要诊疗项目缺失，若有，则抓取违规并提示，并进行下一步，若无，则判断该病案符合判断标准；
S4、人工审核。
实施例2
本实施例为在实施例1的基础上所进行的进一步优化，其具体如下：
必要诊疗项目包括但不限于：手术、检查、检验、药品等项目。
实施例3
本实施例为在实施例1或2的基础上所进行的进一步优化，其具体如下：
每个病例的诊断分为主诊断和次诊断，其中，主诊断对应的必要诊疗项目与次诊断对应的必要诊疗项目不同；
比如：
慢性阻塞性肺气肿作为主诊断时，必要诊疗项目为：抗感染&(支气管扩张剂|平喘|祛痰|支气管镜下治疗)&(肺功能检查|CT|血气分析)；
作为次诊断时，必要诊疗项目为：抗感染|镇咳|祛痰|支气管扩张剂|支气管镜下治疗|平喘；
规则模型根据数据情况及地区特异性调整松紧度。
实施例4
本实施例为在实施例3的基础上所进行的进一步优化，其具体如下：
一般提到的DRG诊断低码高编、治疗不足等违规类型，可通过此规则筛查出的违规病案再进行人工审核、院端申诉等流程后定性，在判断次诊断是否低码高编时，去除该诊断，重调分组，比较两次分组是否相同，并判断组间差价，若两次分组差价大于预设偏差值，且含有必要项未做，则该病案可能存在低码高编。
低标准入院：降低住院标准收住院行为
判断条件1：参保人在一次住院治疗过程中，使用的药品全部为辅助药品时，抓取违规并提示；
判断条件2：参保人在一次住院治疗过程中，未使用任何注射剂药品，且不属于排除条件【物理治疗、康复疗法、中医民族医、高压氧、肿瘤放化疗、肿瘤分子靶向治疗、精神病、白内障、高血压、糖尿病、妊娠】时，抓取违规并提示。
该规则模型可以根据当地数据情况，就排除条件来实现松紧度的调节，当患者不属于低标准入院后，则运行诊断与治疗不符规则。
分解住院：不保证医疗质量，增加住院频率的行为
检查同一个参保人在同一家医院同一科室前后2次住院时间间隔不超过7天，且出院诊断中主要诊断相同的情况，该规则模型可以依据数据情况调整间隔时间，对于特殊疾病、特殊治疗人群等可不运行该规则。
| 姓名 | 入院日期 | 出院日期 | 诊断名称 | 住院费用 |
| 杜A | 2020-5-8 | 2020-5-12 | 子宫内膜非典型增生 | 3830.00 |
| 杜A | 2020-5-13 | 2020-5-21 | 子宫内膜非典型增生 | 14097.63 |
| 郭B | 2020-4-14 | 2020-5-6 | 恶性肿瘤术后放射治疗 | 20264.78 |
| 郭B | 2020-5-8 | 2020-5-13 | 恶性肿瘤术后放射治疗 | 4488.45 |
费用转移：诱导患者门诊、院外购买行为
限制用药规则：不合理用药
根据医保要求将药品限制条件做成符合运行逻辑的规则模型组，包括儿童用药、性别限制用药、中药饮片不予支付、合理用药规则、药品匹配规则、人群禁忌、药品相互作用等，违反相关限制用药规则的予以抓取，提示违规，例如：
| 药品名称 | 剂型 | 禁忌条件 |
| 阿司匹林 | 咀嚼片 | 3个月以下婴儿 |
| 美洛普康 | 注射液 | 15岁以下青少年儿童 |
| 生脉注射液 | 3岁以下儿童 | |
| 可待因 | 注射液 | 18岁以下青少年儿童 |
| 双氢可待因 | 片剂 | 12岁以下儿童 |
| 双氢可待因 | 缓释控释剂型 | 12岁以下儿童 |
| 氨酚双氢可待因 | 片剂 | 12岁以下儿童 |
| 可待因 | 片剂 | 12岁以下儿童 |
| 复方磷酸可待因 | 口服溶液剂 | 18岁以下青少年儿童 |
| 可待因桔梗 | 片剂 | 18岁以下青少年儿童 |
不合理收费规则：某些项目收费不合规定
根据医保要求将诊疗项目做成符合运行逻辑的规则模型，包括诊疗项目限性别规则、诊疗项目限人群规则、项目内涵重复收费规则、项目联用收费限定规则、腔镜按乙类支付规则、限价规则、项目匹配规则、材料匹配规则、手术限价规则等，用于对应违规行为的抓取。
具体监管效果可以凭借抓出的违规金额、违规数量以及准确度来评判，拿某地区2020年1-10月部分疑似违规案例说明：
通过现场抽调数据运行规则模型后，找出该地区某时间段内相应疑似违规病例，在现场实施过程中，第一轮运行规则后再进行人工审核的步骤，依据地区医疗行为的情况调整规则模型，从而保证检出率、准确率及容错率。
例：某肠梗阻病人，住院期间未针对肠梗阻进行相应治疗，出院结算金额为2843.5元，但该地区该医院肠梗阻诊断入组后可得7600元，存在4756.5元的差距，则该医院有治疗不足或低码高编的嫌疑，后续可根据医院申诉材料判断该病例是否确定划分为违规。
该患者出院诊断无糖尿病相关诊断，且结合病案首页及此次住院发生的住院明细可推断可能为非本人带药的情况，提示违规。
尽管上面已经示出和描述了发明的实施例，可以理解的是，上述实施例是示例性的，不能理解为对发明的限制，本领域的普通技术人员在发明的范围内可以对上述实施例进行变化、修改、替换和变型。
Claims (5)
1.一种使用医保审核规则模型进行医疗行为监控的方法，其特征在于，包括如下步骤：
S1、参考临床路径的思路，结合各类疾病指南及专家共识，以每个诊断病例的必要诊疗项目为依据，建立最小单位模块；
S2、将所有最小单位模块组合，构建规则模型；
S3、向规则模型中导入参保人病案，判断病案中诊断是否有必要诊疗项目缺失，若有，则抓取违规并提示，并进行下一步，若无，则判断该病案符合判断标准；
S4、人工审核。
2.根据权利要求1所述的一种使用医保审核规则模型进行医疗行为监控的方法，其特征在于：必要诊疗项目包括但不限于：手术、检查、检验、药品项目。
3.根据权利要求1或2所述的一种使用医保审核规则模型进行医疗行为监控的方法，其特征在于：每个病例的诊断分为主诊断和次诊断，其中，主诊断对应的必要诊疗项目与次诊断对应的必要诊疗项目不同。
4.根据权利要求1或2或3所述的一种使用医保审核规则模型进行医疗行为监控的方法，其特征在于：在判断次诊断是否低码高编时，去除该诊断，重调分组，比较两次分组是否相同，并判断组间差价，若两次分组差价大于预设偏差值，且含有必要项未做，则该病案可能存在低码高编。
5.根据权利要求1所述的一种使用医保审核规则模型进行医疗行为监控的方法，其特征在于：所述规则模型根据数据情况及地区特异性调整松紧度。
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