基于SPO模型的定点医疗机构医保合规管理路径探析  

Exploration of Compliance Management Path for Medical Insurance in Designated Medical Institutions Based on SPO Model

作　　者：梁瑜璠 王岳[2] 

机构地区：[1]华东政法大学经济法学院,上海200042 [2]北京大学医学人文学院,北京100191

出　　处：《中国医疗保险》2024年第9期105-110,共6页China Health Insurance

基　　金：国家卫生健康委员会《基本医疗卫生与健康促进法》重点难点问题研究课题(FZS2018-05)。

摘　　要：为有力打击我国定点医疗机构违规使用、骗取医保基金等行为,提高我国定点医疗机构的医保合规管理能力,本文运用SPO模型,提出构建以“结构(structure)—过程(process)—结果(outcome)”为核心的定点医疗机构医保合规管理体系。建议在结构管理上,设立定点医疗机构医保合规的规章制度及组织架构;在精细化管理过程中,完善“事前提醒—事中监管—事后分析”全流程医保合规运行机制;在结果管理上,建立医保监管平台数据及医患双方医保使用满意度调查反馈机制。本文认为构建定点医疗机构医保合规管理机制能推动我国医保基金管理实现被动监管与主动合规的结合,有利于保障我国医保基金的安全稳定。In order to effectively crack down the illegal and fraudulent use of medical insurance fund by designated medical institutions in China,this article proposes the construction of a designated medical institution medical insurance compliance management system with"structure-process-outcome"as the core,with the SPO model.In terms of the structural management,it is suggested to establish regulations and organizational structures for designated medical institutions to comply with medical insurance regulations.In terms of the refined process management,it is suggested to improve the full process compliance operation mechanism of medical insurance,including"pre-notification,in-process supervision,and post analysis".In terms of outcome management,it is suggested to establish a feedback mechanism of medical insurance supervision platform data and the satisfaction survey of medical insurance use between doctors and patients.The paper shows that establishing a compliance management mechanism for medical insurance in designated medical institutions can promote the combination of passive supervision and active compliance in the management of medical insurance fund,which is conducive to ensuring the safety and stability of medical insurance fund in China.

关 键 词：定点医疗机构 医保欺诈 医保合规管理 SPO模型 

分 类 号：F840.684[经济管理—保险] C913.7[社会学]