Risk identification and prevention and control for medical insurance fund utilization based on fault tree analysis / 中华医院管理杂志

ABSTRACT

Strengthening the supervision of medical insurance funds is an important measure to promote the healthy and sustainable development of the medical security system. In January 2022, a tertiary general hospital in Beijing carried out risk identification and prevention and control practices for the use of medical insurance funds. By using such methods as fault tree analysis and risk matrix, the probability and impact of events were quantitatively evaluated, high-risk events during the use of medical insurance funds were identified, and corresponding risk prevention and control measures were developed, relying on intelligent regulatory systems. From January to November 2022, the hospital outpatient medical insurance refusal amount(20 080 yuan) caused by such high-risk events as exceeding drug instructions, exceeding medical insurance indications, and exceeding age limits decreased by 42.30% compared to the same period in 2021(11 585 yuan). The discharge and settlement time of medical insurance patients decreased from 3 working days to 1 working day. This practice had effectively improved the quality and efficiency of hospital medical insurance fund supervision, improved patients′ medical experience, and provided reference for strengthening the safe and standardized use of medical insurance funds by medical institutions.