I haven't been in contact with Shanghai medical insurance for a long time, about one and a half years. Coincidentally, our hospital software supplier is a foreign enterprise and doesn't know much about Shanghai medical insurance policies, so I participated in the whole project by chance. The director of the Information Department of Shanghai Medical Insurance Center once said that Shanghai medical insurance is the most complicated system in the national medical insurance system, and it will definitely not be taken down in a short time. At that time, I still felt that this statement was a bit exaggerated. After a month of hard work day and night, the main program of our hospital's medical insurance system went online. At that time, I felt that I was quite powerful, but the following things were piled up one after another. After a year and a half of continuous exploration and practice, I dare to say that I have a certain understanding of Shanghai's medical insurance policy and understand what the director of the Municipal Medical Insurance Center said.
Shanghai medical insurance
Let's talk about Shanghai medical insurance from the following six aspects.
1. Types of medical insurance patients
Due to the particularity of Shanghai's status and the complexity of personnel, there are many types of medical insurance patients. Firstly, the types of medical insurance patients in Shanghai are introduced, which are divided into urban workers, urban and rural residents, helping each other, small towns, retired cadres, work-related injuries, college students, military advisers and regiments, and people returning to Shanghai from Xinjiang. Among them, urban and rural residents include severely disabled, elderly, survivors, primary and secondary school students and infants, and the new rural cooperative medical system. These types of people will adopt different reimbursement ratios according to different conditions such as age stage, on-the-job retirement and social security payment.
Second, the referral system-graded diagnosis and treatment system
The country has three levels of diagnosis and treatment, but few provinces have actually implemented it. What Shanghai is doing now is a graded referral system. For example, small towns and residents can only see doctors and fill prescriptions in community hospitals at ordinary times, but they can't go directly to the outpatient department of secondary or tertiary hospitals (except for emergency treatment and hospitalization). How can they go? Personnel have to go to the community hospital for referral first, to which hospital, or which level of hospital, the effectiveness of referral is 3 months, during this period, they can go to the receiving hospital for diagnosis and treatment activities normally. These have achieved a graded diagnosis and treatment system to a certain extent.
III. Settlement of medical insurance expenses
At present, in many places, medical insurance settlement, online real-time settlement and reimbursement after the event are based on medical invoices and related medical documents. Real-time online settlement means that under normal circumstances, when medical insurance patients incur expenses in the hospital, the HIS system will record the expenses and upload the expense details to the medical insurance center in real time. The medical insurance center will calculate how much to reimburse and how much to bear according to the personnel type and the corresponding reimbursement ratio, and then return it to the hospital, and the hospital will settle accounts with the patients. In fact, Shanghai Special does not upload the details when it is uploaded to the hospital for real-time settlement, but uploads the corresponding expenses of each expense category. Moreover, in the details, the hospital needs to reimburse all Class A drugs according to whether the drug is Class A or B drugs, and Class B is classified into three categories: %, 1% and 2%. For example, a drug 1 yuan is 1% of Class B, and the expenses are allocated to the patients before the medical insurance settlement. 1 yuan and 9 yuan enter the medical insurance *. This split into 1 and 9 requires the hospital to calculate itself. For example, the registration fee of 13 yuan is split into 1 (reimbursement) +3 (self-funded) yuan. If all types of people are like this, it is actually not difficult, and it is not difficult to set up these basic materials in advance. However, Shanghai Medical Insurance also stipulates that residents, retired cadres and work-related injuries are not conceited, which means that the above-mentioned rules for these types of personnel will be changed when these hospitals calculate themselves.
IV. Calculation of hospitalization days
Hospitalization is actually nothing special, but there are several points that are quite special. The first point is about the calculation of hospitalization days. Under normal circumstances, the number of days in hospital is calculated according to the way of counting the head and not counting the tail. For example, if you enter the hospital on the 1st and leave the hospital on the 5th, the actual number of days in hospital is 4 days. However, Shanghai medical insurance stipulates that if the patient is admitted to the hospital in the morning (before 12:), then the hospitalization days will be counted as one day, and if the patient is admitted to the hospital in the afternoon, the hospitalization days will be counted as half a day. Similarly, if the patient is discharged in the morning, the last day is not counted, and if he is discharged in the afternoon, it is counted as half a day, so 8.5 days often appear. Of course, this is not only a matter of calculating the number of days in hospital, but also requires patients to record the corresponding hospital bed fee, nursing fee and hospital examination fee for half a day. And hospitals generally do this.
V. Reimbursement of surgical materials
Provisions on reimbursement of some surgical materials, such as artificial joint replacement in orthopedics and internal fixation materials of spine. The medical insurance regulations limit that no matter how many surgical materials you use and how much you spend, the medical insurance will reimburse 15, yuan and 2, yuan for these materials, and all the extra materials will be paid by the patients themselves. Therefore, after each operation, the HIS system will calculate whether the total cost of the materials used for internal fixation or artificial joints exceeds the reimbursement limit. If the cost is 28, yuan, if the excess part needs to be converted into the patient's own expense, the material part is 13, yuan. If it is not exceeded, it will be reimbursed according to normal conditions.
VI. Special day reconciliation
There is another feature of Shanghai medical insurance, which is also a headache for many hospital information departments, that is, daily reconciliation.
as the name implies, daily reconciliation means that you need to check the previous day's accounts with the medical insurance center every day, and check them one by one according to the order of general ledger and subsidiary ledger, such as doctor's name, department, project name, unit, unit price, cost, specification, registration number, etc. However, Shanghai medical insurance requires that the general ledger must be reconciled in 5 days, and both sides are equal, and the subsidiary ledger needs to be uploaded in 7 days. If there is no upload within the specified time limit, or the upload fee is unfair, then the settlement of the medical insurance fee with the medical insurance center will be suspended this month. In the second half of 15 years, the medical insurance revised the rules for daily reconciliation again, stipulating that the detailed expenses should be uploaded and locked once. It may be said that many people don't understand this, so let's briefly talk about the standard database of Shanghai medical insurance:
Shanghai medical insurance has four databases, namely, physician database, diagnosis and treatment project database, drug database and health material database. Every hospital will apply for a physician identification code for its own doctor in the medical insurance physician database, which is the only medical insurance identification code for the doctor in all hospitals in Shanghai. The medical insurance center can know which doctors prescribe which drugs to which patients through daily reconciliation, and can also judge whether the amount of drugs is reasonable according to clinical diagnosis. At the same time, it can also supervise whether doctors are suspected of joint insurance fraud with some personnel, and comprehensively supervise doctors' medical behavior.
The diagnosis and treatment project database contains a complete database of chargeable diagnosis and treatment projects, which contains medical insurance code, price code, project name, price and expense category. All diagnosis and treatment items in the hospital must use the existing names, prices and expense categories in the database.
The drug warehouse and the material warehouse mainly contain reimbursable drug materials, corresponding packaging information and manufacturer information.
these libraries are called standard libraries, which are not static and will be updated from time to time, and the local area needs to change accordingly.
When uploading the expense details, it needs to be completely consistent with these standard libraries. If there are errors such as invalid code, wrong name, wrong company and wrong specification, it means that this expense will be deducted by medical insurance. Suppose a hospital has 2, outpatient visits every day, then the data generated every day may reach tens of thousands of details. These tens of thousands of details need to be compared with the medical insurance one by one the next day. When there is a kind of error, there may be dozens of the same mistakes, and these corresponding detailed expenses will be audited and deducted by the medical insurance, and the seriousness can be imagined.
after the detailed reconciliation is completed, the monthly medical insurance report will be made every month. The monthly report is divided into two parts: one is to generate corresponding payment vouchers (bank payment vouchers) according to personnel types. First of all, the payment voucher has different styles and different contents, which can be roughly divided into the number of visits, account payment in the current year, account payment over the years, and fund payment as a whole. Statistics are made according to the number of employees and retirees respectively. The other is the monthly report, which records and generates all the expenses of patients' medical treatment as dbf files according to the classification of personnel, and also needs to print AB form.
Of course, all the statements must first satisfy their own cross-checking relationship. At the same time, when they are sent to the medical insurance center, there may be errors, such as the center has records but you don't, you have records but the center doesn't, and the expenses are different from the center ...
To sum up, everyone may feel that Shanghai medical insurance is too complicated, and some responsibilities and tasks are handed over to the hospital. At the same time, its checking mechanism is very strict and deductible. However, Shanghai's medical insurance is relatively cautious, and the details are carefully considered. These are all in line with Shanghai's humanities and culture. It is careful and earnest, and it allows you to understand clearly. If the designated medical insurance hospitals are fully implemented in accordance with the medical insurance rules, it can not only standardize the medical behavior of hospitals, but also make the medical expenses transparent. This article is just some of my understanding and sentiment about Shanghai medical insurance, and it is just the tip of the iceberg, which needs continuous learning and exploration.
Further reading: How to buy insurance, which is better, and teach you how to avoid these "pits" of insurance.