异地就医欺诈骗保行为监管困境与路径优化  

Regulatory Dilemmas and Path Optimization of Medical Insurance Fraud in Cross-Site Medical Settlement

作　　者：金志恒 

机构地区：[1]常州大学史良法学院,常州213164

出　　处：《中国医疗保险》2025年第3期44-50,共7页China Health Insurance

摘　　要：异地就医结算面临参保地和就医地的政策差异。在此情境下,违法违规者通过伪造异地就医资料、虚构医疗服务项目或虚报医疗费用、冒名顶替就医等手段骗取医保基金的欺诈骗保行为频发,其具有隐蔽性、复杂性与多重危害性。通过多年的实践,医保系统打击欺诈骗保、维护基金安全的体制机制日趋完善,并取得了显著成效。然而,异地就医结算中对欺诈骗保行为的监管仍面临多重因素制约,主要体现为:医保监管手段相对落后、异地就医环境易滋生道德风险、跨地区协作不畅导致监管薄弱、医保统筹层次尚未实现省级统筹等,增加了监管难度。为了更好地确保制度平稳运行、维护医保基金安全,应在梳理异地就医结算的发展脉络和异地就医结算中欺诈骗保行为特征的基础上,进一步结合监管现状与异地就医特殊情境,着力优化监管路径。There are policy differences between the place of participation and the place of medical treatment in the settlement of medical treatment in a different place face.In this context,fraudulent activities such as forging information of medical treatment from other places,fabricating medical service projects or falsely reporting medical expenses,and impersonating medical treatment to defraud medical insurance funds occur very often,which are covert,complex,and harms.Through years of practice,the mechanism of the healthcare security system to combat medical insurance fraud and ensure the safety of the fund has become increasingly perfect and has achieved significant results However,there are multiple factors restricting the supervision the medical insurance fraud in the settlement of cross-site medical treatment,mainly reflected in the relatively undeveloped means of medical insurance supervision,the easy breeding of moral hazards in the medical treatment in different regions,weak supervision due to poor cross regional cooperation,and the lack of provincial-level medical insurance coordination,which increase the difficulty of supervision.In order to better ensure the smooth operation of the system and the safety of healthcare security,we should focus on optimizing the regulatory path according to the regulatory status quo and the special situation of cross-site medical treatment,based on the development of China's cross-site medical settlement and summary of characteristics of fraudulent insurance behaviors in settlement for medical treatment in different regions.

关 键 词：异地就医 医保基金 欺诈骗保 行为监管 

分 类 号：F840.684[经济管理—保险] C913.7[社会学]