协同治理视角下医保反欺诈机制优化研究

Optimization of social medical insurance anti-fraud mechanism from the perspective of collaborative governance

目的 基于协同治理视角,厘清医保反欺诈机制存在的缺陷,并对其进行优化。方法 通过实地调研和深度访谈等方法收集苏南、苏中、苏北3个样本地区欺诈骗保的相关数据资料,对反欺诈要素构成及运行机制现状进行统计分析。结果 现有的医保反欺诈机制在风险预防、欺诈识别、联动处理以及行业协作等方面存在缺陷,影响反欺诈目标的实现。结论 构建积极主动的风险预防机制、精准高效的欺诈识别机制、衔接有序的联动处理机制、互惠共赢的行业协作机制,可提高医保反欺诈的效率和效果。

Objective To clarify the deficiencies of the social medical insurance anti-fraud mechanism based on the perspective of collaborative governance and to optimize it.Methods The data on fraudulent insurance in the three sample regions of southern,central and northern Jiangsu were collected through on-site investigation and in-depth interviews,and statistical analysis was conducted on the composition of the anti-fraud elements and the current status of the operational mechanism.Results Deficiencies of the social medical insurance anti-fraud mechanism were found in terms of risk prevention,fraud identification,linkage processing and industry coordination,which affected the realization of anti-fraud goals.Conclusions Efficiency and effectiveness of social medical insurance anti-fraud can be improved by constructing a proactive risk prevention mechanism,an accurate and efficient fraud identification mechanism,an articulated and orderly linkage processing mechanism as well as a mutually beneficial and win-win industry coordination mechanism.