[1]马 良,李天俊,冯海欢,等.门诊统筹政策下医院医保基金监管面临的挑战及应对策略[J].卫生经济研究,2026,43(08):28-30.
　MA Liang,LI Tianjun,FENG Haihuan,et al.Challenges and Response Strategies for Hospital Medical Insurance Fund Supervision Under the Outpatient Pooling Policy[J].Journal Press of Health Economics Research,2026,43(08):28-30.
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门诊统筹政策下医院医保基金监管面临的挑战及应对策略

卫生经济研究[ISSN:1004-7778/CN:33-1056/F]

卷:
43
期数:
2026年08期
页码:
28-30
栏目:
医疗保障
出版日期:
2026-07-30

文章信息/Info

Title:
Challenges and Response Strategies for Hospital Medical Insurance Fund Supervision Under the Outpatient Pooling Policy
作者:
马 良1; 李天俊1; 冯海欢1; 李佳瑾1
1.四川大学华西医院，四川 成都 610041
Author(s):
MA Liang;  LI Tianjun;  FENG Haihuan;  LI Jiajin
West China Hospital, Sichuan University, Chengdu Sichuan 610041, China
关键词:
门诊统筹; 医保基金监管; 医院管理
Keywords:
outpatient pooling;  medical insurance fund supervision;  hospital management
分类号:
R197.3
文献标志码:
B
摘要:
实施门诊统筹政策后，医院医保报销审核管理面临门诊统筹基金报销范围判定困难、药品报销审核复杂、流转处方审核责任不明、患者政策理解度不高等问题和挑战。对此，医院应完善医保支付范围系统控制与甄别机制，优化药品报销限制、超说明书审核机制与流程，明确流转处方的审核权责划分，加强政策培训与宣传，从而实现医保基金的高效管理和医疗资源的合理配置。
Abstract:
After the implementation of the outpatient pooling policy, the management of medical insurance reimbursement reviews in hospitals faces challenges such as difficulties in determining the scope of reimbursement for the outpatient pooling fund, the complexity of drug reimbursement reviews, unclear responsibilities for reviewing circulating prescriptions, and patients' limited understanding of the policy. In response, hospitals should improve system controls and screening mechanisms for medical insurance coverage, optimize restrictions on drug reimbursement and review mechanisms and processes for off-label use, clarify the division of responsibilities for reviewing circulating prescriptions, and strengthen policy training and publicity. These measures will facilitate the efficient management of medical insurance funds and the rational allocation of medical resources.

参考文献/References:

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更新日期/Last Update: 2026-07-30