时刻防范医疗保险欺诈风险

The Risk of Social Medical Insurance Should be on Guard Constantly

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。

With the rapid expanding of the insurance coverage and insurance fund amount, the increasing 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. Profit 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 and propagating have been suggested to prevent fraud in health insurance.