社会医疗保险欺诈治理的探索与思考——以昆明市医疗保险反欺诈经验为例

Exploration and Thinking of Social Medical Insurance Fraud Governance——Taking Kunming Medical Insurance Anti-fraud Experience as an Example

医疗保险欺诈的治理工作是医保工作体系的重要组成部分。从内涵和外延看,医疗保险欺诈可分为参保欺诈、内部欺诈和支付欺诈三部分。本文以昆明市医保局的相关数据和代表性案件为例,分析造成目前医疗保险欺诈案件频发的法制、体制困境,并对医疗保险欺诈的综合治理提出几点思考。

The management of medical insurance fraud is an important part of the medical insurance system. In terms of connotation and extension, medical insurance fraud can be divided into three parts： insurance fraud, internal fraud and payment fraud. Taking the relevant data and representative cases of Kunming Medical Insurance Bureau as an example, this paper analyzes the legal and institutional diculties caused by the frequent occurrence of medical insurance fraud cases, and puts forward some suggestions on the comprehensive management of medical insurance fraud.