医保定点医疗机构医疗业务计算机审计方法体系──计算机审计实务公告第39号简版中华人民共和国审计署二○一二年六月目录1.前言............................................................................................................................12.引言............................................................................................................................13.范围............................................................................................................................24.规范性引用文件........................................................................................................25.术语和定义................................................................................................................25.1计算机审计方法..............................................................................................25.2审计业务模型..................................................................................................26.概述............................................................................................................................27.审计方法目录体系....................................................................................................37.1资源分类..........................................................................................................37.2代码结构..........................................................................................................47.3医保定点医疗机构医疗业务计算机审计方法体系......................................58.审计方法实例............................................................................................................68.1通过医疗业务查医保违规审计方法..............................................................68.1.1药品医保自付比例合规性审计方法...................................................68.1.2药品医保自付比例变动合规性审计方法.........................................168.1.3医保“限用药”使用合规性审计方法.............................................268.1.4材料收费超医保限制规定审计方法.................................................358.1.5医疗服务收费超医保限制规定审计方法.........................................468.1.6性别限制药品使用合理性审计方法.................................................548.2医保结算数据核对审计方法........................................................................668.2.1医保结算医疗费用总额核对审计方法.............................................668.2.2医保结算医疗费用明细核对审计方法.............................................778.3医疗服务收费审计方法................................................................................888.3.1医疗服务项目收费标准合规性审计方法.........................................888.3.2医疗服务收费超限额审计方法.........................................................968.3.3医疗服务收费不能同时计收审计方法...........................................1068.3.4医疗服务收费计入不计出审计方法...............................................1218.3.5医疗服务单双侧诊疗项目收费审计方法.......................................1298.3.6门诊挂号就诊情况审计方法...........................................................1378.3.7重复挂号重复收费审计方法...........................................................1458.4医疗服务管理审计方法............................................................
