未来支付系统下的医疗保险退款准确性,1985年至1988年
D C Hsia1, C A Ahern, B P Ritchie
1Office of Inspector General, US Department of Health and Human Services, Baltimore, MD 21207.
JAMA
|August 19, 1992
概括
到1988年,医院的账单错误减少了,减少了与诊断相关的群体 (DRG) 爬行和过度补偿. 虽然医生诊断有时还不够偿还,但计费部门的行动仍然导致过度支付.
科学领域:
- 医疗保健管理的管理
- 医疗计费和编码 医疗计费和编码
- 卫生经济学 卫生经济学
背景情况:
- 准确的国际疾病分类,第九次修订,临床修改 (ICD-9-CM) 编码对于Medicare未来的支付系统退款至关重要.
- 一项先前的研究发现,由于1985年医院账单中的编码错误,与诊断相关的群体 (DRG) 发生了显著的爬行和过度补偿.
- 1985年的DRG爬行不正当地增加了全国估计的3.08亿美元的净退款.
研究的目的:
- 使用1988年的数据,更新一项关于医院计费错误和诊断相关群体 (DRG) 爬行的先前研究.
- 评估编码准确度对1988年医疗保险退款的影响.
- 确定DRG分配差异的原因及其对医院支付的影响.
主要方法:
- 从1988年的2451份医疗保险退院医院病历中抽取一个随机样本.
- 美国医疗记录协会重新抽象了ICD-9-CM代码,并在盲目的基础上分配了DRG.
- 确定了编码差异的原因及其对退款的影响.
主要成果:
- 编码错误在1988年减少到14.7%,比之前的发现减少.
- 1988年,50.7%的DRG错误导致医院过度偿还费用,在全国范围内这一数字并不显著.
- 医生对诊断的错误规范导致退款不足,而计费部门的重新排序导致了过度退款.
结论:
- 证书要求可能已经减少了DRG从医生升级编码的爬行.
- 同行评审组织的努力并没有完全消除医院计费做法造成的DRG爬行.
- 需要进一步改进编码准确性和计费流程,以确保准确的医疗保险退款.
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