美国医疗保障欺诈的内部规制及其启示  

Internal Regulations on American Medical Security Fraud and Its Enlightenment

作　　者：杨华 Yang Hua

机构地区：[1]长春工业大学公共管理学院

出　　处：《医学与法学》2022年第4期39-45,共7页Medicine and Jurisprudence

摘　　要：美国针对医疗保障欺诈不仅强化事后追责的外部规制,且重视以合规管理为核心的内部规制——基于回应性规制理论与风险管理理论的合作规制治理模式,即通过预防针式的合规计划指南与合规计划、自查自纠式的自我披露以及自查协助式的诚信协议架构起干预力度层次递进的体系结构;而我国对定点医药机构建立内部管理制度的立法开启了医疗保障欺诈内部规制的序幕,故有必要在欺诈风险评估、合作规制治理以及鼓励善意合规等方面借鉴他山之石,同时避免规制对象一刀切和偏离以患者为中心的医学目标之不足,助建我国医疗保障欺诈的内部规制体系。The United States not only strengthens the external regulation of post-event accountability for medical security fraud, but also pays great attention to the internal regulation centered on compliance management. Based on responsive regulation theory and risk management theory, namely a cooperative regulation governance model, the hierarchy of intervention is constructed through preventive compliance plan guide and compliance plan, self-disclosure of self-inspection and self-correction, and good faith agreement of self-inspection assistance. And in China the legislation on the establishment of the internal management system of fixed-point medical institutions starts the prologue of the internal regulation on medical security fraud. Therefore, it is necessary to learn from others in the aspects of fraud risk assessment, cooperative regulation governance and encouragement of good-faith compliance to avoid deficiency of deviation from the overall regulation object and patient-centered medical goals.

关 键 词：回应性规制 风险管理 合规计划 自我披露协议 诚信协议 

分 类 号：D971.2[政治法律—法学] DD912.1D922.16