新闻聚焦

首页 > 医疗 > 内容

云南省医疗保险基金管理中心关于2018年省本级城镇职工医疗保险住院医疗费用DRGs付费结算办法

文章来源:    发布时间:2018/5/24 17:15:58    阅读次数:6700     

云南省医疗保险基金管理中心关于2018年

省本级城镇职工医疗保险住院医疗费用

DRGs付费结算办法

  

省本级各定点医疗机构:

根据《国务院办公厅关于进一步深化基本医疗保险支付方式改革的指导意见》(国办发〔2017〕55号)人力资源社会保障部、财政部、卫生部《关于开展基本医疗保险付费总额控制的意见》(人社部发201270号)、云南省人民政府办公厅关于积极推进基本医疗保险支付制度改革的通知(云政办函201425号)、《云南省人民政府办公厅关于推进基本医疗保险支付方式改革的实施意见》(云政办发〔2017〕98号)精神,为进一步加强医保基金收支预算管理,提高医保基金使用的合理、有效,在征求相关单位意见的基础上,中心制订了《2018年省本级城镇职工医疗保险住院费DRGs付费结算办法》,并于2018年4月20日会议通过,现印发给你们,请认真贯彻执行。

                 

 

                   云南省医疗保险基金管理中心

                        20184月25

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

云南省医疗保险基金管理中心关于2018年

省本级城镇职工医疗保险住院医疗费用

DRGs付费结算办法

 

 

第一条  为加强医保基金收支预算管理,建立医院主动控费机制,有效控制医疗费用的不合理增长充分保证医疗质量,保障参保人员的基本医疗,制定本办法。

第二条  本办法适用于云南省医疗保险基金管理中心(以下称省医保中心)协议定点医疗机构发生的省本级职工医保住院费用中属于基本医疗保险统筹基金和大病补充医疗保险支付的费用

第三条  纳入本办法结算范围的定点医疗机构为省本级职工医保人员住院较多且管理较为规范的30家定点医疗机构(以下简称医疗机构)

第四条 2018年年度预算总额62000万元,按照30家医院2017年各月实际发生费用占总费用的占比,2018年各月预算额度详见附件1。

第五条  遵循疾病诊断分组的付费理念ICD-10疾病编码和ICD-9CM-3手术操作编码为基础,根据住院患者疾病诊断、手术名称、项目名称,按照临床专家建议,结合上海联众DRGs分组系统及云南省专家指导意见,确定了724个病组,并采集全省各医院2015年1月至2017年3月实际发生医疗费完成权重计算具体权重详见附件2

第六条  按相同级别相同标准的原则根据30家医院2016年和2017年省本级职工医保出院患者实际发生医疗费用及DRGs分组情况计算支付费率,2018年费率具体详见附件3

第七条  对于入组正确,但患者实际费用大于或等于标准的2.0倍及小于或等于标准的0.3倍的病例,按项目付费方式与医院在月度预算总额内进行结算。按项目过高病例不得超过当月本院省本级职工医保出院患者的5%,按照亏损费用的高低进行排序,将亏损最严重的病例优先列入按项目付费(过高),对于四舍五入导致的未取满5%的情况,将多取一人列入按项目付费(过高)。

第八条  计算公式

每一出院患者结算费用A=病组权重×对应费率

患者住院规定补偿比(报销比例)B=(基本医疗基金支出+大病医疗基金支出)÷(基本医疗统筹共付金额+大病医疗统筹共付金额)

每一出院患者基金支付费用C=(A-全自费金额-挂钩自付金额-起付线自付金额)×B

按项目付费费用D=(基本医保基金支付+大病费用支付)

调节系数E=月度总额控制标准÷(∑C+∑D)

医院结算支付费用F=(∑D+∑C)×E

     第九条  实行“按月拨付,按月结算,年末清算”的方式,即2018年1月至11月根据各定点医疗机构实际发生费用进行拨付,按照DRGs付费每月结算,2018年12月费用待年末清算完毕后,再行拨付,多退少补。定点医疗机构年度内出现欺诈医疗保险基金行为的,结余不奖。                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        

 第十条  对定点医疗机构的服务质量进行年度考核,并依据考核得分确定清算费用。

(一)考核指标:

1.人次人头比 

2.住院期间要求参保患者院内或院外自费购买药品或耗

材人数 

3.有效举报投诉 

4.过度编码或过度诊断 

(二)考核方式

1.人次人头比的考核以各定点医疗机构本院2016年1月至2017年12月的人次人头比为考核指标,每超过一个百分点扣0.5分。详见附件4。

2.住院期间要求参保患者院内或院外自费购买药品或耗材人数,每查实1例扣0.5分,上不封顶。

3.有效举报投诉每次扣0.5分,上不封顶。

4.过度编码或过度诊断。省医保中心将委托省本级DRGs支付试点专家组,组织定点医疗机构病案、医务、医保、临床等部门及科室专家,对定点医疗机构出院病历的第一诊断选择、其它诊断及手术操作填写是否如实反映患者住院真实病情、诊断、治疗等进行检查评估,如经检查评估发现定点医疗机构存在过度编码或过度诊断,并导致分组权重过高的病历,将扣除该病历住院结算的医保基金支付费用,不再结算支付,并对相关情况进行通报。

(三)考核结算公式

指标考核采取百分制扣分法进行统计,总分值保留四位小数。

月度清算费用=定点医疗机构结算支付费用F×(考核得分÷100)

第十一条  为提高医疗机构的服务能力,鼓励医疗机构治疗能力范围内的疑难危重患者,将新技术新项目等特殊病例作为出组病例,省医保中心按项目付费方式与定点医疗机构在年度预算总额外进行结算。该部分费用由定点医疗机构在每月结算前申报,申报时附新技术新项目出院患者清单及新技术新项目申报资料复印件。新技术新项目申报病例不超过当月本院省本级职工医保出院患者的1%。

第十二条  省医保中心定期对纳入按项目付费的病例进行检查,若发现存在不合理医疗不合理费用的情况,将按服务协议进行处理。

    第十三条  符合“病种付费”的住院医疗费用,按照病种结算管理办法执行。

第十四条  省本级参保患者入院后因不同疾病连续在两个科室住院的,按两个疾病费用标准结算。

第十五条  在运行过程中,出现分组、DRGs费用标准、预算总额及相关配套政策与定点医疗机构医院实际情况差异过大时,省医保中心进行适时调整。

第十六条  为规范定点医疗机构的诊疗、疾病编码、入组等行为,形成相互监督的机制,各定点医疗机构的费用、结算、编码、入组等信息相互公开,可互相查阅。

第十  本办法的执行时间为20181月1日至12月31日。

 

附件:1.20181月至12月30家定点医疗机构总额控制月

       度分配表

2.云南省DRGs支付权重

3.2018年云南省省本级职工医保DRGs支付费率

4.2018年度30家定点医疗机构人次人头比考核指标

                    

 

附件.pdf


 

 

 


 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

   

网站地图

主办单位:云南省人力资源和社会保障厅  运行维护:云南省人力资源和社会保障厅信息中心

联系方式:0871-12333  滇ICP备10002878号  网站标识码:5300000003

版权所有,未经授权,不得转载、引用