第 二 篇 經 營 成 效 與 品 質 提 升
Chapter 2 Achievements &Quality Assurance Initiatives
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資訊科技提高審查效率
利用電腦資訊科技，發展電腦醫令自
動化審查系統，針對支付標準、藥價基準、
藥品給付規定、審查注意事項等給付規定，
明確規範不給付之規定（例如年齡限制、
性別限制、申報次數限制、不可併同申報
項目、不得實施部位等），建立醫令自動
化審查邏輯，透過醫療院所申報資料，進
行電腦邏輯程式檢核，直接核減不給付醫
令項目，以減少醫療院所不當申報之情形，
並逐步導正醫療院所申報之正確性，以提
升審查效率。
總額支付制度全面實施後，健保署積
極建立以檔案分析為主軸之審查制度，進
行醫院醫療利用異常之審查管理，目前已
採行之措施，舉例如下：
1.
依據各項統計資料分析、偵測病患就醫、
醫療院所診療型態與費用申報之異常狀
況，供審查參考，使專業審查重點由個
案審查轉變為診療型態的審核。
2.
邀請醫界代表討論，共同發展檔案分析審查
異常不予支付指標，利用申報資料對醫療院
所診療型態進行審核，並針對各指標值設定
閾值，就異常部分，以程序審查方式進行核
減（統扣），以節省人工審查成本。
Highly Efficient Automated Auditing System
The NHIA has developed an automated auditing system
with its own internal logic that can screen payment claims
submitted by medical institutions against such criteria as the
NHI reimbursement schedule for services or drugs, drug
payment rules or other standards for specific treatments or
drugs (such as age, gender or frequency parameters or services
that cannot be combined). By weeding out expense claims that
do not conform to regulations, the system reduces the number
of improper requests and prods health care providers into
improving the accuracy of their claims, further enhancing audit
efficiency.
After the global budget payment system was fully
implemented, the NHIA developed an auditing system built
around profile analysis that looks for potential anomalies in
how hospitals treat patients and use resources. The features of
this profiling system to date include:
1.
Detecting through statistical analysis abnormalities in patient
visits and medical institutions’ diagnosis and treatment
practices and reimbursement claims, and turning over the
results to the experts handling professional reviews. The
focus of the professional review then shifts from individual
claims to the health care provider’s practice and operating
patterns.