source: the Ji'nan times
Ji'nan city low insurance family led the medical insurance card
medical insurance patients to the hospital, but was "shut out". In the near future, the reporter received some medical insurance participants, and some designated medical institutions in Ji'nan refused to treat the patients with medical insurance, or set restrictions on the hospitalization of the insured patients. In this regard, the head of the medical insurance Department of Ji'nan said that changing the settlement method of medical insurance is to reduce unreasonable expenses.
patient: with the medical insurance card, the patient who was refused
was accidentally dropped in August 12th, and was sent to a large hospital for examination. The doctor said he needed to be hospitalized and had a minimally invasive operation. When she was in hospital, she wanted to go according to the medical insurance procedure, but she was told that the medical insurance card in the hospital was temporarily unusable. Ms Liu asked the hospital staff to register the medical insurance card first, and then reimburse it when it could be used, but the other side said it could not register.
helpless, the family had to pay a deposit in hospital, and admitted to the spinal surgery department of the hospital. On the 13 day, Ms. Liu did a minimally invasive operation, and her family consulted the hospital. The answer was that the medical insurance card could not be used. In August 17th, Ms. Liu discharged from the hospital, and the staff of the spine surgery said that medical insurance cards could not be used before March next year because the medical insurance costs of the first half of the Department had exceeded the annual quota issued by the medical insurance office of the hospital.
hospital: the investigation of the
reporter of the change of medical insurance settlement method found that Ms. Liu's encounter was not an example, and some medical insurance patients had experienced similar experiences.
Why did individual hospitals refuse to receive medical insurance? A doctor who did not want to be named said that the situation in the hospital was related to the "total amount control, the total advance payment" of the medical expenses and settlement measures which our city had implemented since July. According to the payment method of new medical insurance expenses for urban employees medical insurance, the original cost per capita has become the total cost and the total number of people's assessments. In this way, some hospitals will allocate the total annual cost and total number of people from the medical insurance department according to the proportion of the total hospital collected by the medical insurance patients in the first three years, and distribute it to the related departments in the hospital, and the departments are equally assigned to each month. In this way, if the quota is full in this month, the hospital will have to return the medical insurance to the hospitalized patients "shut out" or ask for their own treatment.
Health Insurance Department: the total amount control is to limit the unreasonable behavior
City medical insurance department head, before implementing the total amount control, the medical insurance settlement in our city is mainly based on "per capita hospitalization quota", supplemented by the settlement according to the disease, the settlement of the treatment project, bed day and bed day fee. The settlement mode based on per capita hospitalization cost is simple and easy to operate, but the loopholes are large, which causes some hospitals to break down the illegal phenomena such as hospitalization, repeated hospitalization, excessive inspection, excessive use and excessive treatment, resulting in the loss of a large number of medical insurance funds.
implementing total control is to change the medical insurance department to manage separately for the medical insurance department and the hospital. This year, the city medical insurance office and the three class a comprehensive fixed-point medical institution have added the terms of overall fund total control in the service agreement, which limits the total number of inpatients and the total cost. These restrictions are mainly aimed at problems such as unreasonable repeated hospitalization, the breakdown of hospitalization and the irrational use of fees.
dispute: the medical insurance fund to the hospital is not enough
the statement that "medical insurance office to reduce the overall fund of the hospital" put forward to some hospitals, the head of the medical insurance Department said that the total amount of medical insurance fund to the hospital this year is the comprehensive expenditure in recent years, the scientific calculation and determination, deducts the unreasonable The cost, compared with last year, has not only decreased but also increased. In addition, the medical insurance department has also prepared some medical insurance co ordinate fund.
recently, the municipal human resources and Social Security Bureau and other departments called the relevant responsible persons of the relevant hospitals to hold a forum. The Bureau said that the next step will further standardize the management of the medical insurance fund within the hospital, resolutely correct the illegal practices of "layer subcontracting" in a few hospitals, ensure the timely hospitalization of medical insurance patients, increase the inspection of the designated medical institutions, and find the behavior of the people passing the medical insurance. Deal with it. It is understood that at present, individual hospitals have basically solved the problem of prevarication of medical insurance patients.