1. It is necessary to divide the reportable and non-reportable items from the itemized list of medical expenses. For each disposal fee, treatment cost, verify to the specific details, and distinguish the out-of-pocket expenses;
2, must be every examination, treatment, drugs, disposal and medical records to check, to ensure that all expenditures are real and reliable;
3, in the audit of the medical records should pay attention to whether the patient is covered;
4, must be the use of drugs reasonably audit, to ensure compliance with the terms of the insurance contract. The review of the rationality of the use of medicines must be carried out to ensure compliance with the terms of the insurance contract, and to check whether the medicines belong to the three medical insurance catalog. In general, this position is mainly to review the medical records, invoices and medication details provided by the claimant, to determine which expenses should be paid by the Company, and to eliminate those medications that are not related to the accident and those that are beyond the scope of the medical insurance, so as to finally determine the amount of compensation that should be paid.
I. Non-disease treatment program class
1, various weight loss, fat gain, increase program 2, various beauty and fitness, non-functional cosmetic surgery, orthopedic surgery, etc.. All kinds of preventive health care treatment program 4, a variety of health checks 5, all kinds of medical consultations and medical identification 6, dental malformation and dental porcelain.
Two, the service category
1, out-of-hospital consulting fees, registration fees, medical fees, etc. 2, the examination of the expedited fee, the consultation fee surcharge, the designated surgical fee, high quality and low price, special care service fee please special care fee.
Three, the category of treatment programs
1, myopic orthopedics 2, a variety of organ transplants or tissue transplants of organs or tissue sources 3, heart valves, kidneys, corneas, blood vessels, bone, skin and bone marrow transplants other than the transplantation of organs or tissues 4, health care and nutritional therapies, music therapies, qigong therapies, magnetic therapies, and other complementary treatment programs. Diagnostic and therapeutic equipment and medical materials
1, eyes, eyeglasses, limbs, dentures, hearing aids and rehabilitation equipment2, large-scale medical equipment such as positron emission tomography, electron beam ct, ophthalmology excimer laser treatment device and other large-scale medical equipment for examination and treatment.
1, the availability of patients admitted to the hospital who can be treated on an outpatient basis.
2. Whether the charges, examination, medication, and treatment are reasonable, i.e., "four reasonable", and whether the medical advice, checklist, cost list (prescription), and record of the course of the disease are consistent with the network system, i.e., "five consistent".
3, the application of antibacterial drugs in accordance with the "antibacterial drug classification and management system", there is no overdose, a variety of combined, over the course of medication.
4, whether the medical records are true, there is no copy of the medical records, inspection reports, signature on behalf of the patient.
5, whether the grasp of the indicators of hospitalization follow the relevant norms.
6, is it in accordance with the provisions of the inspection of the valid documents of patients admitted to the hospital? Is there any impostor, there is no hanging bed phenomenon?
7, whether there is an expansion or falsification of the condition of the drugs in exchange for diagnosis and treatment items? Whether there is a false diagnosis and treatment program or extend the time of diagnosis and treatment.
8, whether there will not be paid for diagnostic and treatment items, medicines and consumables and other directories to record the scope of payable in an altered manner.
9. Whether there is any test that is not related to the disease.
10, whether there is a violation of medical services, price policy, unauthorized increase in fees, decomposition of charges, private charges?
I hope the above can help you, if there are still questions please consult a professional lawyer.
Legal basis:
Article 4 of the Social Insurance Law of the People's Republic of China
Employers and individuals within the territory of the People's Republic of China pay social insurance premiums in accordance with the law, and have the right to inquire about the payment records, personal rights and interests records, and to request the social insurance agency to provide social insurance consulting and other related services.
Individuals enjoy social insurance benefits in accordance with the law, and have the right to supervise the payment of contributions for them by their own units.
Article 5
The people's governments at or above the county level incorporate the cause of social insurance into their national economic and social development plans.
The State raises social insurance funds through multiple channels. The people's governments at or above the county level give necessary financial support to the social insurance cause.
The State supports the social insurance cause through preferential tax policies.
Article 30 of the Social Insurance Law of the People's Republic of China
The following medical expenses shall not be included in the scope of payment by the basic medical insurance fund:
(1) those that should be paid out of the Workers' Compensation Insurance Fund (2) those that should be borne by a third party (3) those that should be borne by the public ****health (4) those that are sought outside the country.
Medical expenses shall be borne by the third party according to law, the third party does not pay or cannot determine the third party, the basic medical insurance fund to pay first. The basic medical insurance fund shall have the right to recover from the third party after the first payment.