[1]王日珍,吴群红,单凌寒,等.基于典型案例的定点医疗机构医保违规行为监管研究[J].卫生经济研究,2022,39(11):12-15.
　WANG Rizhen,WU Qunhong,SHAN Linghan,et al.A Study on the Regulation of Medical Insurance Violations in Designated Medical Institutions based on Typical Cases[J].Journal Press of Health Economics Research,2022,39(11):12-15.
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基于典型案例的定点医疗机构医保违规行为监管研究
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卫生经济研究[ISSN:1004-7778/CN:33-1056/F]

卷:
39
期数:
2022年11期
页码:
12-15
栏目:
医疗保障
出版日期:
2022-10-26

文章信息/Info

Title:
A Study on the Regulation of Medical Insurance Violations in Designated Medical Institutions based on Typical Cases
作者:
王日珍1; 吴群红1; 单凌寒1; 覃英华1; 李嘉程1; 郭朋飞1; 刘俊萍1; 马云霞1; 高珊珊1
1.哈尔滨医科大学卫生管理学院，黑龙江 哈尔滨 150081
Author(s):
WANG Rizhen;  WU Qunhong;  SHAN Linghan;  QIN Yinghua;  LI Jiacheng;  GUO Pengfei;  LIU Junping;  MA Yunxia;  GAO Shanshan
School of Health Management, Harbin Medical University, Harbin Heilongjiang 150081, China
关键词:
定点医疗机构; 医保违规行为; 精细化监管
Keywords:
designated medical institutions;  medical insurance irregularities;  refined regulation
分类号:
F840.684
文献标志码:
A
摘要:
目的：分析我国对定点医疗机构违规使用医保基金行为的监管障碍，为医保基金精细化治理提供依据。方法：运用内容分析法，构建“违规行为-法律法规-监管网络”分析框架，对国家医保局曝光的58个定点医疗机构违规使用医保基金典型案例进行分析。结果：医保违规行为，以过度诊疗、违规收费、串换项目和超范围结算为主，分别占21.92%、15.75%、13.01%和12.33%，民营医院的违规行为更加复杂多样；地方医保部门是医保违规行为的监管主体，多种监管方式并用，处理方式以追回医保基金为主。结论：加强医保基金监管法律法规、监管主体和监管方式的协同，对违规行为进行精细化治理，同时引导定点医疗机构加强自律建设。
Abstract:
Objective To analyse the barriers to the regulation of irregularities in the use of medical insurance funds by designated medical institutions in China and to provide a basis for the refined governance of medical insurance funds. Methods Using the content analysis method, we constructed an analytical framework of "irregularities - laws and regulations - regulatory network" and analyzed 58 typical cases of irregularities in the use of health insurance funds by designated medical institutions exposed by the National Health Insurance Bureau. Results The main violations of health insurance were excessive medical treatment, illegal fees, item substitution and over-scope settlement, accounting for 21.92%, 15.75%, 13.01% and 12.33% respectively, while the violations of private hospitals were more complex and diverse. Conclusion It is suggested to strengthen the synergy of laws and regulations, regulatory bodies and regulatory methods for the supervision of medical insurance funds to fine-tune the treatment of irregularities. Furthermore, it is necessary to guide designated medical institutions to strengthen their self-regulatory construction.

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更新日期/Last Update: 2022-10-26