医疗保险基金欺诈骗保及反欺诈研究

Research on Medical Insurance Fund Fraud and Anti-fraud

医疗保险基金欺诈案件频繁发生,对医疗保险制度运行和发展危害巨大。文章在梳理近年来社会上影响较大的医疗保险基金欺诈、骗保案例以及从道德风险的角度分析欺诈骗保的核心逻辑的基础上,借助COSO风险管理框架,提出了基于流程的医疗保险基金反欺诈体系,包括健全防范机制、有效识别测量、强化调查研究和严格惩治约束。基于该框架,通过系统介绍国际医疗保险基金反欺诈的经验,发现诸多国家或地区形成了多层次的精准识别机制,进行科学审慎的调查评估,构建全方位的反欺诈惩治约束网络。为此,建议中国亟需建立法律层面的医疗保险反欺诈规范,政府应吸纳市场和社会的力量,引入第三方服务,多方协同提升医保智能审核,并利用大数据等技术构建反欺诈监控网络,积极营造全民反欺诈的文化氛围,同时,还需要进一步深化医疗卫生管理体制和医药流通体制改革,为防治医疗保险欺诈创造和谐的制度环境。

The frequent occurrence of fraudulent medical insurance funds has done great harm to the operation and development of the medical insurance system. The paper first sorts out the cases of medical insurance fund fraud which have great effect on the society in recent years. Then it analyzes the core logic of fraud insurance from the perspective of moral hazard. With the help of COSO( The Committee of Sponsoring Organizations of the Treadway Commission) risk management framework,the paper puts forward the anti-fraud system of the medical insurance fund based on the process,including the sound prevention mechanism,the effective identification and measurement,the intensive investigation and the strict punishment and restraint. With this framework,the paper systematically introduces the experience of the international medical insurance fund against fraud. It is found that many countries or regions have formed a multi-level precision recognition mechanism to carry on a scientific and prudent investigation and evaluation and construct an omni-directional anti-fraud punishment and restraint network. For this reason,the paper suggests that China urgently need to establish the legal level of medical insurance anti-fraud norms. The government should absorb the market and social forces,introduce third party services to promote intelligent auditing of medical insurance,build anti-fraud monitoring network by using large data and other technologies,and actively create a national cultural atmosphere for the anti-fraud. At the same time,it is necessary to further deepen the medical and health management system and the medical circulation system to create a harmonious system environment for preventing medical insurance fraud.