基于典型案例的定点医疗机构医保违规行为监管研究  

A Study on the Regulation of Medical Insurance Violations in Designated Medical Institutions based on Typical Cases

作　　者：王日珍 吴群红[1] 单凌寒[1] 覃英华 李嘉程 郭朋飞 刘俊萍 马云霞 高珊珊 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;不详)

机构地区：[1]哈尔滨医科大学卫生管理学院,黑龙江哈尔滨150081

出　　处：《卫生经济研究》2022年第11期12-15,共4页

基　　金：国家社会科学基金重点项目“国家医疗保障基金监管手段与创新模式研究”(19AZD013)。

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。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 selfregulatory construction.

关 键 词：定点医疗机构 医保违规行为 精细化监管 

分 类 号：F840.684[经济管理—保险]