协同治理视角下医保基金欺诈行为监管体系优化研究

Research on the Optimization of Supervision System of Medical Insurance Fund Fraud from the Perspective of Collaborative Governance

摘要: 目的：医保欺诈行为造成医保基金的严重损失。基于协同治理视角，从监管主体、监管客体、监管手段和反馈机制四个维度优化社会医疗保险欺诈骗保行为监管体系。方法：通过对样本地区现场调查和相关人员的深度访谈，了解各地医保欺诈行为及监管现况。结果：研究发现，样本地区存在着部门间信息不共享，联合监管机制运行受阻、医保欺诈界定不够明确，基金监管立法层次较低、监管力量不充足，专业化水平偏低、互惠共赢的协同治理氛围未形成，治理主体的主动性偏弱等问题。结论：发展医保智能化监管，完善联合监管机制、丰富立法，细化医保监管的法律法规、加强稽核队伍专业化培训，规范医保信息编码体系、营造互惠共赢的协同治理环境，加强治理主体激励举报机制。

Abstract: Objective: Medical insurance fraud causes serious losses to medical insurance funds. Based on the perspective of collaborative governance, the supervision system of social medical insurance fraud and fraud is optimized from four dimensions: supervision subject, supervision object, supervision means and feedback mechanism. Through on-the-spot investigation and in-depth interviews with relevant personnel in sample areas, we can understand the current situation of medical insurance fraud and supervision in various places. Results: The study found that there are some problems in the sample areas, such as the lack of inter-departmental information sharing, the obstruction of joint supervision mechanism, the lack of clear definition of medical insurance fraud, the low level of fund supervision legislation, the lack of supervision power, the low level of specialization, the lack of mutual benefit and win-win collaborative governance atmosphere, the weak initiative of governance subjects and so on. Conclusion: Intelligent supervision of medical insurance, improvement of joint supervision mechanism, enrichment of legislation, refinement of laws and regulations of medical insurance supervision, strengthening of professional training of audit team, standardization of medical insurance information coding system, mutual benefit and win-win collaborative governance, and strengthening of incentive and reporting mechanism of governance subjects.