医保基金监管的方式、成效与困境

The Way, Effect and Dilemma of Medical Insurance Fund Supervision

目的:通过分析眉山市医保基金监管现状,提出完善医保基金监管的建议。方法:采用访谈法、描述性统计,分析眉山市医保基金监管现状及存在的问题。结果:眉山市医保基金智能审核系统上线后检查效率明显提高,专项检查范围与力度逐渐加强,有效规范了定点医药机构的诊疗行为;但存在监管部门设置不规范,监管力量不足,部分审核规则效用减弱,基金监管法律依据不足,长效监管机制尚未建立等问题。建议:规范各区县监管部门设置,充实专业监管队伍,探索购买监管服务,根据医疗服务行为的变化完善智能审核规则,加快推动医保基金监管法制化,协同各部门推动医保信用管理体系建设。

Objective To put forward some suggestions for improving the supervision of the medical insurance fund by analyzing the current situation of medical insurance fund supervision in Meishan city. Methods Interviews and descriptive statistics were used to analyze the current situation and existing problems of the medical insurance fund supervision in Meishan City. Results After the intelligent audit system of medical insurance fund in Meishan City was launched, the inspection efficiency was significantly improved, the scope and intensity of special inspection were gradually strengthened, and the diagnosis and treatment behavior of designated medical institutions was effectively standardized;however, there were some problems such as irregularities in the establishment of supervisory departments, insufficient supervisory power, weakened effectiveness of some audit rules, insufficient legal basis for fund supervision, and a long-term supervisory mechanism that has not yet been established. Conclusion Standardize the establishment of supervision departments in various districts and counties, enrich the professional supervision team, explore and purchase supervision services, improve the intelligent audit rules according to the changes in medical service behavior, speed up the legalization of medical insurance fund supervision, and cooperate with various departments to promote the construction of medical insurance credit management system.