After the actual payment of DRG, in order to effectively solve the problems existing in the actual operation of DRG payment, promote the diagnosis and treatment of medical institutions to be more standardized and reasonable, and the management to be more refined and scientific, encourage designated medical institutions to admit and treat difficult and serious diseases, and prevent the occurrence of prevarication of patients and insufficient diagnosis and treatment, special cases such as abnormal treatment costs for designated medical institutions need to be implemented for special diseases. The special disease single negotiation can effectively promote the reasonable development of medical institutions, and the special cases of medical institutions can be compensated by appropriate medical insurance funds.
Declaration conditions
Special application for project-based billing cases only includes the following five cases:
(1) Cases of emergency treatment or death after emergency rescue efforts were ineffective.
(2) Cases of new technology projects that have been filed with the handling agency.
(3) Cases where the number of days of hospitalization is greater than 60 days.
(4) High-magnification cases.
(5) Cases with extremely high costs.
Review cycle
For the special cases that meet the requirements of the current year, the designated medical institutions shall, before the year-end liquidation, apply to the medical insurance agency through the system for the special disease single discussion, and the medical insurance agency will no longer accept the application for the special disease single discussion before the year-end liquidation.
Application materials
When submitting the application, it is necessary to submit the specific reason and provide the corresponding supporting materials (including inpatient cases, the first page of the medical record, medical records, doctor's orders, examinations, laboratory reports, surgical records, special drugs, special consumables or the use of special examinations and treatments, etc.), and if necessary, it is necessary to cooperate with the provision of supplementary materials, and if the corresponding supporting materials cannot be provided, the application will be deemed invalid. According to the number of cases applied, the review shall be organized in a regular manner, but the review of special diseases shall be completed before the deadline for year-end liquidation.
Judging content
(1) Compliance and policy compliance checks:
Ensure that the application process and materials of the medical institution comply with the relevant policies and regulations to avoid non-compliance.
Review whether the medical institution has complied with the special reimbursement policies and regulations of the health insurance department.
(2) Assessment of the special circumstances of the case:
Review whether the case is special, such as whether it involves a new technology project, whether it is a rare case, whether the condition is particularly complex, etc. These conditions may require special management to ensure that the patient receives appropriate medical care.
(3) Review of clinical necessity and reasonableness:
Check whether the medical measures are clinically necessary, i.e. whether the services provided are in line with the patient's medical needs and are not overtreated or ineffective.
Evaluate whether the treatment plan and the drugs used and the tests meet the clinical practice standards and national regulations.
(4) Fee review:
Double-check the costs of medicines, examinations, surgeries, care, etc., to ensure that they are reasonable and match the services provided.
For cases where the cost is too high, it is necessary to focus on reviewing the reasonableness and necessity of it, and whether there are behaviors such as excessive examinations, packaging fees, and surgical decomposition fees, so as to prevent unreasonable growth of medical expenses.
(5) Coding and data accuracy verification:
Verify whether the coding of the main diagnosis and surgical operation of the case is accurate to ensure the correctness of the DRG grouping.
Check whether the case data is complete and true to avoid data errors or omissions, which may affect the accuracy of DRG payment.
Source | DRG Academy
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