tai Benh vien da khoa tinh Bac Ninh) Cong tac giam dinh BHYT la mot trong nhung nhiem vu chinh va phai thuong xuyen lien tuc cua co quan BHXH, co y nghia trong viec giam sat viec Chi quy kham chua benh BHYT sao cho chi dung, chi du chi phi KCB cho nguoi benh theo dung quy dinh cua Nha nude, bao dam quyen lpi KCB cho ngudi tham gia BHYT, tranh tham hut quy KCB BHYT. Thong qua cong tac giam dinh chi phi kham chua benh tai co sd dieu tri, co quan BHXH thuc hien viec thanh quyet toan chi phi KCB BHYT cho co sd kham chua benh. Quy trinh giam dinh BHYT tai Benh vien da khoa tinh Bac Ninh dupe the hien qua Hinh 2.3.
De dap ung yeu cau thuc te cua benh vien, Bao hiem xa hoi tinh Bac Ninh da cu 04 can bo giam dinh thuong true tai benh vien gom 01 Bac sy, 02 y sy, 01 ke toan, phoi hpp chat che vdi benh vien tuyen truyen cho ngudi benh ve Luat bao hiem y te sua ddi nam 2015, kiem tra thu tuc hanh chinh theo quy dinh, giai quyet vudng mac ve thu tuc kham chua benh, ve quyen lpi, ve trach nhiem cua ngudi tham gia bao hiem y te va cua co sd y te.
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Nhiem vu cua giam dinh vien thuong true tai Benh vien da khoa tinh Bac Ninh bao gom:
- Phoi hop voi nhan vien cua co so kham chua benh tiep don benh nhan, kiem tra luu giu the, phiSu KCB BHYT, huong dan nguoi benh di kham theo day truyen, vao so theo doi, quan ly benh nhan.
- Tiep xuc voi nguoi benh tai cac khoa phdng de tim hieu tinh hinh cung cap dich vu y te, giai quyet vuong mac cua nguoi benh BHYT va tu van che do BHYT cho moi doi tuong.
- Thuc hien ky thuat giam dinh chat luong, so luong, don gia thuoc, cac dich vu y te, vat tu tieu hao... de xac dinh tong chi phi cua nguoi benh BHYT lam co so cho co quan BHXH thanh toan voi co so kham chua benh; huong dan co so KCB su dung cac bieu mau thong ke trong cong tac KCB BHYT.
r r
2.2.3. Giam dinh bao hiemy tetoil Benh vien eta khoatinh Bac Ninh 2.2.3.1. Kiem tin thu tuc Kham chua benh BHYT
Tai Benh vien da khoa tinh Bac Ninh, co quan BHXH tinh da bo tri giam dinh vien BHYT chu tri phoi hop voi can bo cua benh vien tien hanh kiem tra thu tuc KCB BHYT ngay tai khu vuc don tiep benh nhan va khu vuc dieu tri noi tru.
Ben canh do, khi xay ra mot so truong hop vi pham, giam dinh vien BHYT se tien hanh giai quyet, xu ly cac truong hop vi pham theo quy dinh huong dan cong tac giam dinh BHYT. Cu the
a. Tai khu vuc don tiep ngudi benh
Trong giai doan 2011 - 2015, tai khu vuc don tiep nguoi benh cua Benh vien da khoa tinh Bac Ninh chi bo tri duy nhat 1 giam dinh vien tai quay tiep don nguoi benh. Giam dinh vien tien hanh kiem tra thu tuc KCB ban dau truoc khi lam thu tuc KCB cho benh nhan:
- Kiem tra the BHYT hoac giay to thay the the BHYT.
- Kiem tra giay chuyen vien va cac loai giay to thay the giay chuyen vien.
Trong giai doan 2011 - 2015, qua thuc hien kiem tra thu tuc KCB BHYT tai khu
vuc don tiep benh nhan, giam dinh vien da phat hien mot so truong hop vi pham trong su dung the BHYT. Trong nam 2011, giam dinh vien da phat hien 139 truong hop vi pham, den nam 2015, giam dinh vien da phat hien 382 trudng hop vi pham, tang 2,17 lan so vdi nam 2011. Nguyen nhan vi pham phan lon la so the BHYT khong khop theo ho so cua co quan BHXH tinh, mot so trudng hop muon the BHYT, the BHYT da het han su dung,... Doi vdi cac trudng hop vi pham nay, giam dinh vien thuc hien thu hoi the BHYT vi pham, tuy nhien, trong giai doan 2011 - 2015, chua co bat cu trudng hop vi pham nao bi lap bien ban. Chinh vi vay, viec xu ly vi pham tai khu vuc don tiep benh nhan moi chi mang tinh hinh thuc, chua du ran de doi vdi ngudi vi pham.
Ben canh do, qua thuc hien cdng tac kiem tra thu tuc ban dau dang ky KCB BHYT tai Benh vien da khoa tinh Bac Ninh, Benh vien da tu choi chi tra doi vdi nhung trudng hop vi pham trong su dung the BHYT neu tren va mot sd trudng hop dang ky KCB khong thuoc trudng hop duoc hudng BHYT.
Bang2.8. Tinh hinh phat hien viphamtrong cong tac kiem tra thu tuc KCB BHYT tai Benh vien da khoa tinh Bac Ninh giai doan 2011 - 2015
(Nguon: Bao caocdngtacgiam dinh BHYT tai Benhvien dakhoatinh BacNinh) Nam
•> r
Tong so luol dang ky KCB
So trudng hop chap nhan the
BHYT
Sd trudng hop tu choi the
BHYT
Sd trudng hop vi pham
2011 5.091 3.983 969 139
2012 6.766 3.912 2.699 155
2013 9.026 6.093 2.648 285
2014 9.711 6.932 2.460 319
2015 10.873 8.126 2.365 382
Sd lupt benh nhan dang ky KCB tai Benh vien da khoa tinh Bac Ninh tang len do nhu cau ve kiem tra sue khoe dinh ky cung nhu dien bien tinh hinh dich benh tren dia ban tang len. Dieu nay gay sue ep ve khdi luong cdng viec lon doi vdi giam dinh vien tai quay don tiep benh nhan. Chinh vi bo tri nhan luc giam dinh vien tai
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quay chi co duy nhat 1 ngudi, vi vay, da xay ra tinh trang kiem tra thu tuc KCB BHYT khong hieu qua, gay mat thdi gian doi vdi ngudi benh cung nhu cac thu tuc KCB BHYT khong duoc kiem soat day du.
b. Tai khu vuc dieu tri noi tru
Trong giai doan 2011 - 2015, tai khu vuc dieu tri noi tru cua Benh vien da khoa tinh Bac Ninh, cong tac kiem tra thu tuc KCB bang the BHYT duqc thuc hien qua hinh thuc kiem tra dinh ky hoac dot xuat kiem tra tai cac khoa, phong dieu tri va kiem tra thu tuc KCB ddi vdi benh nhan xuat vien.
Cong tac kiem tra dinh ky duqc thuc hien hang thang bao gom 2 giam dinh vien bao gom 1 can bo tai co quan Bao hiem xa hoi tinh Bac Ninh va 1 bac sy chuyen khoa. Cac giam dinh vien thuc hien kiem tra dinh ky thong qua ddi chieu sd luqng benh nhan cd ten trong sd cap thuoc cua khoa, phong vdi sd luqng benh nhan thuc te dang nam dieu tri tai cac buong benh tai Benh vien.
Cong tac kiem tra dot xuat duqc thuc hien bdi 1 can bo tai co quan Bao hiem xa hoi tinh Bac Ninh. Tren co sd ddi chieu cac thong tin ghi tren benh an vdi Bang ke chi phi kham chua benh: ho ten, tuoi, dia chi, sd the BHYT, gia tri su dung cua the, chan doan, ma chan doan duqc luu tru tai phong Hanh chinh - quan tri, can bo giam dinh xac dinh tinh hqp phap, day du cua cac chu ky tren benh an, tren Bang ke chi phi kham chua benh de dam bao tinh hqp phap, hqp ly cua chung tu thanh toan chi phi kham chua benh BHYT theo dung quy dinh cua Bo Y te va Bo Tai chinh.
Qua thuc hien cong tac kiem tra dot xuat va dinh ky, giam dinh vien da phat hien mot sd trudng hqp vi pham ve sd luqng benh nhan dang ky cap thuoc khong khdp vdi danh sach; mot sd trudng hqp xuat vien nhung qua Bang ke chi phi kham chua benh khong hqp ly. Trong nam 2011, can bo giam dinh da tir choi thanh toan 17 trudng hqp va yeu cau benh nhan chi tra vien phi phat sinh do sai pham la 1,8 trieu ddng. Den nam 2015, sd trudng hqp vi pham phat hien
la 19 truang hap, yeu cau benh nhan chi tra vien phi phat sinh do sai pham la 5,7 trieu dong.