智能审核：重塑医保监管生态提升医保服务质效

Core Viewpoint - The article emphasizes the importance of regular supervision of medical insurance funds to ensure their safe operation, improve usage efficiency, standardize medical service behaviors, and reduce the burden on patients seeking medical care. Traditional regulatory methods are inadequate in addressing new types of violations arising from reforms in medical insurance payment methods, necessitating a shift towards intelligent auditing using big data and smart technologies [1][2][3]. Group 1: Development of Intelligent Auditing - The development of intelligent auditing has been guided by policies since 2018, with significant milestones including the promotion of real-time monitoring and strict regulation of medical behaviors [2]. - By 2023, the National Medical Insurance Administration aims to implement a nationwide intelligent monitoring system, with a goal of establishing a standardized and scientific auditing framework by the end of 2025 [2][3]. Group 2: Features of Intelligent Auditing System - The intelligent auditing system features a layered architecture that integrates diverse data sources, enabling real-time analysis and monitoring of medical expenses [4]. - A dynamic and flexible rule engine is central to the system, allowing for the adaptation of auditing rules based on evolving medical policies and practices [5]. Group 3: Impact on Medical Insurance Regulation - The intelligent auditing system significantly enhances the efficiency of medical insurance regulation, processing over 20 million cases daily with an accuracy rate exceeding 92% [7]. - It establishes unified standards and objective rules, improving the credibility and authority of medical insurance oversight [7]. Group 4: Governance and Collaboration - The system promotes a shift from external control to internal motivation for compliance among medical institutions, encouraging proactive adherence to regulations [8]. - It fosters a collaborative governance model where feedback from medical institutions can lead to the dynamic updating of rules, enhancing the system's accuracy and inclusivity [8]. Group 5: Enhancing Service Quality - Intelligent auditing improves settlement efficiency for insured individuals, enhancing their sense of satisfaction and security regarding medical services [10]. Group 6: Future Outlook - There is a need for improved policy interpretation and training for medical staff to ensure a better understanding of auditing rules and standards [11]. - Emphasis on data security and privacy protection is crucial, given the sensitive nature of medical insurance data [13]. - The establishment of relevant laws and regulations is necessary to support the legal and compliant application of intelligent auditing technologies [14].