中文摘要：

目的：分析医保拒付原因,并提出合理化建议,为定点医院加强管理提供参考依据。方法：分析武汉市某三甲医院2015年医保拒付情况,进行分类汇总,采取前后对照研究,分析干预前后医保拒付金额的变化。结果：干预前,医保拒付金额211185元,拒付率1.69%。通过一系列干预措施,医保拒付得到有效控制,并逐步下降,拒付金额最低下降至20637元,拒付率最低下降至0.16%,下降率为90.23%。结论：医保拒付管理是一项连续性、不间断的工作,贯彻落实医保政策、严格病案书写制度可以逐步稳定地规范医院管理,降低医保拒付,模拟智能审核程序则是一种有效的管理工具,是有效降低医保拒付的直接手段。

英文摘要：

Objectives：To analyze the reasons of medical insurance funds refuse to pay and put forward reasonable suggestions and to provide reference for strengthening the management of medical insurance contracted hospital. Methods：Materials of health insurance withhold payment from 2015 were collected in a top tertiary hospital. Dates were classified and changes before and after intervention were comparatively analyzed. Results：Before the intervention, the amount of health insurance withhold payment is $211185, the rejection rate is 1.69%. Through a series of measures, the amount of withhold payment have been gradually decline. The minimum amount of health insurance withhold payment is $20637 and the lowest rejection rate is 0.16%, decreased is 90.23%. Conclusions： The management of health insurance withhold payment is a continuous work. Strict implementing medical insurance policy and medical record writing can gradually standardize hospital management and decrease the amount of withhold payment. Simulative computer audit program is a kind of effective tool to direct reduce the health insurance withhold payment.