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医疗机构药品医保拒付风险分析及药师主导的干预模式探索
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| 篇名： | 医疗机构药品医保拒付风险分析及药师主导的干预模式探索 |
| TITLE： | Risk analysis of drug-related medical insurance claim denials in healthcare institutions and exploration of phar-macist-led intervention model |
| 摘要： | 目的 构建药师主导的降低药品相关医保拒付风险的干预模式，为医疗机构落实医保基金监管主体责任提供实践参考。方法药师运用风险矩阵法对2024年我院药品相关医保拒付数据进行风险评估，针对高风险因素（医保适应证不适宜、超支付疗程、性别和年龄不适宜等），从组织架构、技术防控、闭环管理3个维度制定干预措施。比较2024年（干预前）和2025年（干预后）药品相关医保拒付数据变化和干预后前置审方系统拦截效果。结果干预后，我院药品医保拒付金额较干预前下降57.24%，拒付条目数从10108条下降至2892条。其中，因医保适应证不适宜、超支付疗程、性别不适宜、年龄不适宜而拒付的条目数分别下降70.94%、74.26%、83.86%、96.70%。前置审方系统全年累计拦截不符合医保限定支付要求的门诊处方药品金额560.5万元、住院医嘱药品金额468.3万元。我院药品医保拒付金额占全院医疗项目医保拒付金额的比例下降至19.7%。结论药师主导的多部门协同、技术防控与动态优化相结合的全流程干预模式，可操作性强，实践效果显著，对降低药品相关医保拒付风险具有重要价值。 |
| ABSTRACT： | OBJECTIVE To develop a pharmacist-led intervention model for reducing drug-related medical insurance claim denial risks， so as to provide practical references for healthcare institutions in fulfilling their primary responsibility for medical insurance fund supervision. METHODS A risk matrix method was employed by the pharmacists to assess the risks associated with drug‑related medical insurance claim rejections in our hospital during 2024. Intervention measures were developed targeting high‑risk factors (including inappropriate indications for medical insurance coverage, exceeding the covered treatment course, and inappropriateness of gender and age) from three dimensions, namely organizational structure, technical prevention and control, and closed‑loop management. Changes in drug‑related claim rejection data were compared between 2024 (pre‑intervention) and 2025 (post‑intervention), and the interception effect of the pre‑prescription review system was evaluated after the intervention. RESULTS After the intervention, the total amount of drug‑related medical insurance claim rejections in our hospital was reduced by 57.24% compared with that before the intervention, and the number of rejected items decreased from 10 108 to 2 892. Specifically, the number of rejected items due to inappropriate indications, exceeded treatment course, inappropriate gender, and inappropriate age was reduced by 70.94%, 74.26%, 83.86%, and 96.70%, respectively. Throughout the year following the intervention, a total of 5.605 yuan million in outpatient prescription drug amounts and 4.683 million yuan in inpatient medication order amounts that did not meet the insurance‑limited payment requirements were intercepted by the pre‑prescription review system. The proportion of drug‑related claim rejection amount to the total medical service claim rejection amount of our hospital decreased to 19.7%. CONCLUSIONS The pharmacist-led multi-department collaborative， technical prevention and control， and dynamic optimization integrated full-process intervention model is highly operable and has significant practical effects. It has important promotion value in reducing drug-related medical insurance claim denial risks. |
| 期刊： | 2026年第37卷第14期 |
| 作者： | 王晓兰；潘杰；葛意；吕波；周倩；施爱明 |
| AUTHORS： | WANG Xiaolan，PAN Jie，GE Yi，LYU Bo，ZHOU Qian，SHI Aiming |
| 关键字： | 风险矩阵; 医保拒付; 药学干预; 前置审方 |
| KEYWORDS： | risk matrix; insurance claim denial; pharmaceutical intervention; pre-authorization of prescriptions |
| 阅读数： | 1 次 |
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