Analysis of Medical Insurance Settlement of High Rate Cases and Study on Related Influencing Factors

Wu Dekai; Zhang Hongcheng; Pan Yu; Tan Zaixiang

Abstract：Objective To study the settlement of high-rate cases in the year-end final accounts of medical insurance,and the factors affecting the comprehensive settlement rate,and improve the reform of medical insurance payment methods.Methods The medical insurance final accounts of a hospital in 2023 were described and statistically analyzed.2 test and Mann-Whitney U test were used to compare the difference between high rate cases and normal rate cases,and linear multiple regression was used to explore the influential factors affecting the comprehensive settlement rate.Results The settlement rate of resident medical insurance was lower than that of employee medical insurance,the settlement rate of high rate cases was lower,and the allocation rate of some low weight high rate cases was negative,and the hospital did not get reasonable compensation.Compared with the normal rate,the proportion of acute and critical cases in high rate cases is higher,and the cost and time consumption are higher.The factors influencing the comprehensive settlement rate are high rate limit,settlement point value,cost ratio,total medical cost,benchmark points and reimbursement ratio in descending order.Conclusion Under the current policy,the high rate cases have not been reasonably compensated.The medical insurance department should work out the identification standard and settlement method of high rate cases scientifically and reasonably together with medical institutions.