In recent years, the national direct settlement of remote medical treatment has achieved phased results, and the national medical insurance service platform, Sichuan medical insurance APP and other platforms have continuously improved the remote medical treatment inquiry and filing functions, providing more channels for the insured people to handle it, so that the insured people can enjoy more convenient direct settlement services for remote medical treatment. However, there are still "blockages" and "pain points" in the filing process of remote referral personnel, which damages the medical experience of insured patients. Effective referral filing can not only reduce or reduce the threshold fee, but also increase the reimbursement ratio of medical insurance. In order to effectively protect the medical insurance treatment of insured patients, the Medical Insurance Bureau of Zhongjiang County, Deyang City, conducted in-depth research, focused on the "key small things", and strived to turn the "problem list" into a "satisfaction list" for the masses.
First, there is a problem
(1) To complete the formalities, you must "run around"
Referred patients need to fill in the referral form with the doctor in charge first, and then bring the referral form and relevant materials to the medical insurance office for filing and registration after being approved and signed by the department director, the medical insurance department of the hospital, and the dean in charge. The departments of the hospital are distributed in different buildings, and the medical insurance handling window is a certain distance from the hospital, and patients must travel to multiple points to complete the filing procedures.
The picture shows the doctor communicating about the referral
(2) The process is cumbersome and often "intestinal obstruction"
In the referral approval process, if the approver is not present at any link, there will be "intestinal obstruction" in the whole process, and if the next day is a holiday, then you can only continue to wait. Severe and emergency patients are often unable to file and register in time due to the delay in the approval process, which may lead to the inability to conduct direct online settlement when settling outside the city, and need to return to the insured place for manual reimbursement after paying in full, or resulting in a low reimbursement ratio and increasing the burden of medical treatment.
(3) Business sinking meets "can't wait"
The Medical Insurance Bureau of Zhongjiang County, Deyang City, will sink the filing matters of remote medical treatment to the medical insurance service station of the designated medical institution, and the service station will regularly submit the information that has completed the filing to the county medical insurance office window for review. Under normal circumstances, patients do not need to keep the referral filing information, but some patients are worried that the hospital in other places needs to be consulted, and only the signature of the transfer hospital is not complete, and they can't wait for the service station to submit the information, so they go to the medical insurance handling window to stamp, resulting in "more runaways".
Second, the main practices
Comprehensively sort out the referral filing process, coordinate hospital and medical insurance resources, optimize service functions, and link the handling personnel of medical institutions and medical insurance bureaus "behind the scenes", so that the data can "run all the way", and patients will go from "running all the way" in the past to "zero meeting" and "zero errands", so as to solve the worries of patients for referral.
(1) Digital empowerment and building technical support
Relying on the internal office system of designated medical institutions, the referral approval module is developed, the approval account of the county medical insurance bureau is opened, the hospital side sets up the referral application and three-level approval authority, and the medical insurance party sets up the final review authority, so as to realize the online flow of the whole process of referral application and approval. At the same time, the mobile office system APP is used to realize the handheld approval anytime and anywhere, which empowers and reduces the burden on the handling personnel, breaks through the time and space limitations of the approval work, and promotes the speed and efficiency of the approval service.
The picture shows the doctor filling out the referral form in the system
(2) One-stop service, seamless connection of remote filing
Give full play to the role of medical insurance service stations, turn "passive acceptance" into "active service", and realize the seamless connection of referral review and remote filing. After both the medical insurance and the hospital complete the online referral approval, the referral information will be pushed to the medical insurance service station of the designated medical institution, which will directly accept it, handle the filing and registration of the patient for remote medical treatment, and simultaneously complete the archiving of the referral form, the registration form for remote medical treatment, and the copy of the ID card. After the referred patients go through the referral procedures in the hospital, they can complete the filing and registration of medical treatment in other places in a "one-stop" manner, and there is no need to go through the filing separately.
(3) Strengthen reviews to prevent and resolve major risks
Establish a referral review mechanism for the filing of medical treatment in other places, determine a special person to be responsible for the approval of the referral, regularly review the filing materials for referral for medical treatment in other places handled by the medical insurance service station, provide timely guidance on issues such as the filing and registration process and non-standard data archiving, and urge the medical insurance service station to rectify in a timely manner, so that the "simplified" process does not "reduce" the responsibility, strictly control the quality of the referral personnel for the filing of medical treatment in other places, and continuously improve the level of medical insurance services.
Third, the results have been achieved
(1) Guarantee the medical insurance benefits of patients who are referred to participate in insurance
The use of the online approval process allows the filing of referral to other places to achieve "zero obstruction" completion, and comprehensively eliminates the situation that the medical burden on the insured patients is increased due to the inability to settle online and the need to pay in advance or the reimbursement ratio and amount are reduced due to the lack of time for filing. Since 2021, 10,757 people have been referred online for non-local filing, and the satisfaction of the masses has been greatly improved.
The picture shows the completion of the filing and registration of the medical insurance service station
(2) Form a new model of "Internet +" medical insurance services
With the in-depth advancement of the construction of smart hospitals, the internal office and approval systems of designated medical institutions have been gradually improved, and the medical insurance department can directly rely on the internal system of medical institutions to carry out online approval business on the mobile terminal. This model has the advantages of low investment, low threshold, and replication, and can be quickly promoted to all designated medical institutions to build an efficient "Internet +" medical insurance service model.
(3) The service of medical insurance service stations is more convenient and efficient
The approval process will be transferred online, eliminating the need to carry paper application forms to and from medical institutions and medical insurance handling windows for signatures, and truly realizing "one-stop" handling at medical insurance service stations in designated medical institutions by allowing data to "run more", so that the sinking medical insurance service items can be implemented. Ensure that the insured people have access to high-quality and efficient medical insurance services.
Author | Deyang Medical Security Bureau, Sichuan Province
Source | China Medical Insurance
Edit | Yang Zixuan, Liu Xinyu
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