“三无”医院骗保问题解析及防范

Analysis and Prevention of “Three None” Hospital's Medicare Fraud

通过对云南"三无"医院骗保事件进行剖析,从骗保现象入手得出该事件的本质是权利寻租,通过对我国此类医保欺诈的行为因素进行分析,得出卫生体制不合理、付费机制存在缺陷、监管缺乏、法律缺失是引起此类医保欺诈的主要原因,并提出相应措施:制度改革,引入竞争;复合型支付方式,完善共付制;建立反欺诈机构,加强人才培养;完善管理机构,改变基金管理方式;构建法律体系;加强行业三方监督;建立社会监督评价机制。

This paper analyzes the incident in depth ,starting from the fraudulence phenomenon in “Three None” Hospital in Yunnan ,concludes the nature of the event is right rent-seeking .According to the analysis of behavioral factors about this kind of insurance fraud , unreasonable health system , defect payment mechanisms , lack of supervision , lack of legal provisions are the main reasons .So that appropriate measures are proposed ：institutional reform ,introduce competition system ; use compound payment methods , improve co-payment system ; establish an anti-fraud agency , strengthen personnel training ;improve the management agencies ,change fund management ;build a legal system ;strengthen the tripartite regulation ;establish social supervision and evaluation system .