Core Insights - The traditional medical insurance management model is inadequate to meet the growing demands of fund supervision, hospital operation management, and patient experience enhancement, necessitating the integration of AI and big data to create a smart management ecosystem [1] Group 1: System Reconstruction - The hospital's medical insurance office has innovatively constructed a "smart terminal + cloud service + digital supervision" system, achieving a leap from isolated breakthroughs to systematic reconstruction [2] - The introduction of 300 fifth-generation smart terminals has reduced the medical insurance settlement time from 3 minutes to 30 seconds, enhancing patient experience [2] - The "Zhejiang Second Hospital Good Doctor" app has upgraded service processes, enabling 100% real-time cloud review of online prescriptions for 1,400 doctors, and reduced average patient visits from 6.8 to 2.7 times per year [2] Group 2: Fraud Risk Reduction - The implementation of the smart management system has led to a 42% reduction in medical insurance fund fraud risk [3] - To assist elderly patients who may struggle with smart terminals, the hospital has introduced a "Silver Age Channel," maintaining 20% of manual service windows and providing 40 digital guides [3] Group 3: Innovative "Three Commons Model" - The hospital's medical insurance office has established a "Three Commons Model" focusing on standard co-construction, data sharing, and shared responsibility to reform payment methods and ensure efficient use of medical insurance funds [4] - The office has analyzed five years of referral data to create a payment standard for 36 disease types suitable for primary care, promoting "same disease, same price" policies [4] - The integration of real-time settlement functions into a remote consultation system has facilitated direct settlement of hospitalization and outpatient expenses across provinces, reducing the occupancy rate of tertiary hospital beds [4] Group 4: Support for New Technologies - The hospital has explored the integration of new medical technologies with insurance payments, successfully adding 20 new techniques to the insurance directory [5] - As a pilot unit for brain-computer interface payment trials, the hospital is participating in the national initiative to support this key area [5] - Recommendations include establishing an "Innovative Technology Payment Fund" to support early applications of breakthrough technologies and creating a risk-sharing mechanism to ensure actual efficacy aligns with expectations [6] Group 5: Next-Generation Smart Management System - The hospital is developing a next-generation smart medical insurance management system that includes real-time data monitoring and a digital twin model for fund flow [6] - The system will feature intelligent decision support, a cost-effectiveness evaluation model, and a machine learning framework for new technology value assessment [6] - It aims to simulate the economic impact of payment policy adjustments and provide optimized transfer payment solutions for fund regional balance [6]