What does medical insurance audit mean?

Medical insurance audit is actually the position of medical auditor of insurance company. Generally speaking, this position is mainly to review the medical records, invoices and medication details provided by the claims adjuster, determine which expenses should be paid by the company, eliminate those drugs unrelated to this accident and drugs beyond the scope of medical insurance, and finally determine the amount of compensation. Specifically, the duties of medical auditors are as follows:

1. It is necessary to distinguish reportable items from non-reportable items from the detailed list of medical expenses. For each disposal fee and treatment fee, check the specific details and distinguish the self-funded items.

2, must check every check, treatment, drugs, disposal and medical records, to ensure that all expenses are true and reliable.

3. Pay attention to whether the patient is covered by insurance when viewing the medical records.

4, must review the rationality of drug use, to ensure compliance with the terms of the insurance contract, check whether it belongs to the three major medical insurance directory of drugs.

It can be seen from the specific responsibilities of this post that in order to successfully perform this job, workers need to be familiar with the diagnosis, treatment and nursing programs of various diseases, as well as the actual clinical operation procedures and indications of various auxiliary examinations, treatments and drugs, and be familiar with the price standard of medical services. Therefore, people who usually need to apply for a job have certain practical experience and relevant professional knowledge. Of course, the specific recruitment requirements can go to the recruitment information released by the corresponding insurance company.

What is the development prospect of medical audit in insurance companies? With the development of science and technology, I personally think this position is more replaceable. The development of personal career prospects is not only related to social background, but also related to the development degree of the company and personal career planning. Therefore, you can choose a large-scale insurance company in the industry, which has strong protection and relatively considerable welfare benefits in all aspects. I also want to plan my future career development and work hard. I believe it will be a well-developed job.

The medical insurance card is used to see a doctor, buy medicine and reimburse medical expenses to pay for medical examination. The part of the medical expenses of the insured that should be paid by the basic medical insurance fund shall be settled directly by the social insurance agency with the medical institutions and pharmaceutical business units.

Measures for handling medical insurance: if an employee has an employer, he can ask the employer to prepare relevant materials, register social security for him according to law, and pay medical insurance premiums according to law; Employees who are unemployed can prepare their own ID cards and other materials, declare social security registration to social security agencies, and pay medical insurance fees according to the approved amount.

legal ground

Article 28 of People's Republic of China (PRC) Social Insurance Law

Medical expenses that meet the basic medical insurance drug list, diagnosis and treatment items, medical service facilities standards and emergency rescue shall be paid by the basic medical insurance fund in accordance with state regulations.

Article 29 of People's Republic of China (PRC) Social Insurance Law

The medical expenses of the insured shall be paid by the basic medical insurance fund, and shall be directly settled by social insurance agencies, medical institutions and pharmaceutical business units.

Article 23 of People's Republic of China (PRC) Social Insurance Law

Employees should participate in the basic medical insurance for employees, and employers and employees should pay the basic medical insurance premiums in accordance with state regulations.

Individual industrial and commercial households without employees, part-time employees who have not participated in the basic medical insurance for employees and other flexible employees can participate in the basic medical insurance for employees, and individuals pay the basic medical insurance premium in accordance with state regulations.

Article 58 of People's Republic of China (PRC) Social Insurance Law

The employing unit shall, within 30 days from the date of employment, apply to the social insurance agency for social insurance registration for its employees. If the social insurance has not been registered, the social insurance agency shall verify the social insurance premium it should pay.

Employees-free individual industrial and commercial households who voluntarily participate in social insurance, part-time employees who do not participate in social insurance in the employing unit and other flexible employees shall apply to the social insurance agency for social insurance registration.