时刻防范医疗保险欺诈风险 The Risk of Social Medical Insurance Should be on Guard Constantly.pdfVIP

观察思考 时刻防范医疗保险欺诈风险 张 杨 （黑龙江省社会 医疗保险局 哈 尔滨 150036 ） 【摘要 】随着近年来参保覆盖面和基金规模的迅速扩大，定点服务机构的大量增加 以及社会对 医疗保险 的认知度增强，医疗保险欺诈 问题 日趋严峻，欺诈的形式和手段也开始 向组织化和 隐蔽化发展 。从形式上 主要分为 ：虚假 的就 医事件、虚假 的待遇享受或支付资格、违规 医疗服务行为等。利益驱动是 医疗保险欺 诈的主 因，此外，医疗保险欺诈的发生还存在着诸 多诱 因，包括 ：法制建设不完善、社会道德 的缺失、监 管力量薄弱、医疗卫生资源配置不合理、医疗保险管理服务水平有待提 高等。因此，应该通过提 高监管能力、 深化 医药卫生体制 改革、提升 医疗保险管理水平、建立诚信机制、加 强社会监督、加 强宣传等措施 防范 医 疗保险欺诈风险。 【关键词 】医疗保险 ；欺诈 ；风险防范 【中图分类号 】F840.684 C913.7 【文献标识码 】 A 【文章编号 】1674-3830 （2014 ）10-19-3 doi:10.369/j .issn.1674-3830.2014.10.5 The Risk of Social Medical Insurance Should be on Guard ConstantlyZhang Yang (Social Medical Insurance Bureau of Heilongjiang Province, Harbin, 150036) With the rapid expanding of the insurance coverage and insurance fund amount, the increasing 【Abstract 】 number of designated health care institutions, and the high acknowledgement of health insurance, the cheating behaviors in health insurance is getting worse and worse. The cheating patterns and methods have become sophisticated. The cheating patterns include fraud in treatment, illegibility for reimbursement, and false treatment. Profi t is the main cause of insurance cheating. Besides, imperfect legislation, low moral value, weak supervision, improper distribution of health care resource, and low level of insurance management are all contributed to the cheating. Therefore, intensifying insurance monitoring system, deepening the health care system reform, increasing the ability of insurance management, establishing trust mechanism, emphasizing social monitoring an