As a payment method, DIP's core function is to provide a basis for medical insurance departments to pay fees to designated medical institutions, and the specific cost settlement process between them must be clear. This not only makes the settlement work evidence-based and rules-based, but also helps to alleviate the pressure of medical institutions' capital operation and improve the timeliness and accuracy of expense settlement. We summarize and refine the contents and key technologies that need to be paid attention to in the process of fee settlement, hoping to help the settlement of DIP pilot cities.
1. Scope of application of DIP settlement: DIP settlement is a settlement method between medical insurance departments and designated medical institutions, and the settlement of hospitalization expenses between insured persons and designated medical institutions is not affected by DIP settlement for the time being.
Scope of application Diseases: The biggest feature of DIP is that it is based on a large number of medical data samples. At present, the DIP directory covers nearly 99% of the cases except psychiatric, rehabilitation and nursing long-term hospitalization cases.
Second, the calculation of medical insurance fund payment 0 1. Calculation method of payment standard for sick groups
Calculation formula: payment standard of disease group =DIP score * settlement point value.
02. Calculation method of medical insurance payment
Calculation formula: The total hospitalization expenses that the medical insurance fund should pay to the designated medical institutions according to DIP = ∑ [(payment standard of the sick group in the DIP group where the insured is hospitalized-out-of-pocket expenses-deductible line) * medical insurance reimbursement ratio]-∑ It is suggested to deduct the expenses.
03. Example
We used the example of conservative treatment of acute appendicitis cited by Ying Yazhen, vice president of the National Medical Security Research Institute, for actual combat drills. The details are as follows:
Medical insurance payment for conservative treatment of acute appendicitis = [disease score (0.306)× settlement score unit price (14,400 yuan)-out-of-pocket expenses (900 yuan)-specific out-of-pocket expenses (0 yuan)-deductible line (600 yuan)]-suggested deduction expenses (60 yuan) = 2,846.4 yuan, as shown in the following figure:
Note: Out-of-pocket expenses are medical expenses beyond the scope of medical insurance drug list, diagnosis and treatment items and medical service facilities; Specific out-of-pocket expenses refer to some high-value materials or articles. According to the local medical insurance policy, some individuals should pay first, and the other part should be included in the scope of medical insurance payment. Deductible refers to the part that should be paid by the individual first within the scope of local medical insurance policy; The proportion of medical insurance reimbursement is the proportion of payment reimbursement within the policy scope stipulated by local medical insurance; Suggested deduction refers to the abnormal expenses found according to the Supplementary Catalogue of Illegal Activities Supervision.
It is worth noting that when extreme phenomena occur, if the out-of-pocket expenses are greater than the difference between the payment standard of the sick group and the specific out-of-pocket expenses and deductible lines, which will result in the result that the DIP should pay ≤0, it will be paid as 0.
Three. Appropriation and liquidation of medical insurance fund When we determine how much to pay, what remains is how the medical insurance agency should pay the hospital. According to the requirements of national DIP technical specifications, it generally includes the following four contents: fund pre-allocation, monthly pre-settlement, annual pre-settlement, and annual liquidation.
0 1. Fund advance payment
Medical insurance agencies set up working capital according to a certain proportion of the total control index. For the designated medical institutions that have not violated the relevant management regulations of medical insurance within two years and have good assessment results, they will be paid to the designated medical institutions in advance at the beginning of the year according to a certain proportion of the total annual medical insurance payment of the designated medical institutions in the previous year. The proportion is determined by each application area according to the local actual situation, and the proportion is usually set to 1 to 2 months.
02. Monthly budget settlement
Judging from the definition of disease score, medical insurance institutions are unified with medical institutions at the end of the year. However, in order to reduce the prepayment pressure of medical institutions, medical insurance agencies settled some expenses for medical institutions in advance. Because the annual fractional price can only be calculated after the end of medical service activities at the end of the year, the monthly cost is estimated according to the situation of the month, which not only pays the fee but also informs the medical institutions of the fractional situation, killing two birds with one stone. It is implemented in three stages:
(1) data summary stage (to be completed before the 7th of next month)
The main work of the medical insurance agency is to determine the total amount of the monthly pre-settlement fund of each medical institution on the premise of confirming the accounting amount of the overall fund of the cases included in the DIP settlement scope and summarizing the accounting expenses of the monthly overall fund of each designated medical institution.
(2) Pre-settlement data check stage (completed before next month 15)
The main work of the medical insurance agency is to adjust the monthly pre-settlement data by using the DIP auxiliary catalogue on the premise of completing the monthly liquidation work, and at the same time feed back the data to the designated medical institutions for verification.
(3) Determine the monthly pre-settlement result stage (completed before 25th of the following month)
The medical insurance agency completes the calculation of a series of indicators of monthly pre-settlement, and forms the final monthly pre-settlement result. After the data is summarized, it is submitted to the corresponding departments and distributed to medical institutions according to accounts payable. We use a picture to summarize:
03. Annual pre-liquidation
Annual pre-liquidation mainly refers to checking data with medical institutions and data preprocessing before formal liquidation, including the calculation of DIP index and the evaluation of medical institutions' medical insurance assessment. See the following figure for the specific implementation process of annual pre-liquidation:
04. Annual liquidation
The annual liquidation refers to the final allocation of medical institutions by the agency according to the results of the annual pre-liquidation, and the annual final allocation amount is the difference between the year-end liquidation amount, the annual monthly pre-settlement amount and the pre-allocation amount. The specific flow chart is as follows:
Through the in-depth study of DIP payment and settlement rules, we can see from another angle that DIP has implemented the settlement rules of "monthly prepayment and monthly pre-settlement", which has shortened the feedback time of relevant regulatory authorities, timely and effectively corrected unreasonable medical treatment behavior, and fully embodied its concept of scientific fee control.
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