我国定点医疗机构医疗保险相关违规行为及其监管研究

Research on Violation Behaviors at Appointed Medical Insurance and its Regulation in China

我国医疗保险制度不断发展和完善,在解决群众"看病难、看病贵"问题上发挥了重要作用。但由于相关配套政策尚不完善、监管机制不健全等原因,出现了一系列骗取、套取医保资金的违法、违规行为,给国家和人民造成很大的经济损失。本文主要从定点医疗机构医保相关违规行为的现象入手,分析违规行为产生的原因和形成机制,总结各地工作经验,并提出政策建议,以期为卫生行政部门下一步工作提供参考依据。

The regular improvement and enhancement in the national medical insurance policy have played a decisive role in solving ＂hard to treatment, expensive to treatment＂ problem. However, due to some other reasons, such as insufficient supporting policies, low-effective regulation mechanism, a series of law-breaking and regulation-violation behavior occurs, such as medical insurance cheat, which caused drastic economic damage to the nation and the people. Through starting from some relevant regulation-violation of appointed medical institutions, the reason and original behind these illegal activities are analyzed, and the experience from different areas is summarized, and recommendations to the current policy are proposed to provide some references for the following work.