美国医保欺诈监管中的联邦医保项目排除制度及其启示

Federal Health Care Program Exclusion Institution in the U.S.Health Care Fraud Regulation and its Implications

如何遏制医疗保障欺诈是一个世界性难题。联邦医保项目排除制度是美国医疗保障反欺诈制度系统中一个颇具威慑力的行政监管工具。制度将特定的违法违规医药供方纳入“被排除个人和组织名单”并向社会公布,同时对其采取支付禁止和从业限制措施。本文对该制度的产生与历史演进、内容设计和制度实施展开分析,认为该制度在内容设计上受到了趋于强化威慑的联邦医疗保障反欺诈的整体立法进路的影响。联邦法律通过对名单的列入条件进行详细而涵盖面宽的规定、设置严厉的联动惩戒措施和提供有力的组织保障来塑造制度的威慑力。同时,通过差异性的排除类型和期限设置标准赋予制度一定的弹性,以促进其有效应对复杂多样的欺诈行为。在制度实施中,监管机构利用回应性监管策略和“排除豁免”政策来避免依法监管过于僵化、不利于医药供方的遵从、对医药服务供给造成负面影响等问题。联邦医保项目排除制度在运行机理上与中国当前公共治理领域兴起的行政黑名单制度具有相似性。通过对该制度的系统研究,希望为中国医保基金监管领域的黑名单制度建设提供启示和借鉴。

How to curb health care fraud is a core issue for governments across countries.The Federal health care program exclusion is an administrative and regulatory tool with strong deterrent effects in the U.S.health care anti-fraud system.The exclusion institution puts certain health care providers in violations of laws and regulations on the“List of Excluded Individuals and Entities”and publicizes the list.Meanwhile,it imposes payment prohibition and employment restriction on the excluded providers.By analyzing the establishment and historical evolution of the institution,its current design and implementation,this paper argues that the institutional design has been shaped by the overall federal legislative approach of strengthening deterrence against health care fraud violations.The institution's deterrent effects are arguably ensured by the detailed and inclusive stipulation of exclusion imposition conditions,stringent joint administrative sanctions,and enhanced enforcement resources and capabilities.Differential exclusion types and criteria for exclusion periods give the institution flexibility to respond effectively to complex fraudulent behaviors.During the implementation,the regulatory agency employs a responsive regulation strategy and the“exclusion waiver”measure to avoid problems of the rigid law enforcement that sometimes isn't conducive to providers'compliance and causes adverse effects on health care provision.The exclusion institution shares some operational similarities with the administrative blacklist system being developed in China.Through a systematic study of the institution,this paper attempts to provide implications for the construction of a blacklist system for health care funding supervision in China.