三级公立医院医保违规行为及原因分析

Cause Analysis of Medical Insurance Violations in Tertiary Public Hospitals

目的:分析三级公立医院医保基金使用存在的问题及原因,对医院医保基金使用监管提出建议。方法:对2021年医保飞行检查的资料进行梳理与总结,并结合文献资料与访谈结果对问题进行分析。结果:重复收费、超标准收费、药品超医保支付范围和串换项目在医院医保违规情形中占比较高。违规行为主要分为不当逐利行为、低效行为和偏差行为三类。结论:建议完善相关法律法规和制度规范,动态监测医院医保违规行为并及时上报,加强监管部门人才队伍建设,增强医保政策的兼容性,探索开展医保医师制度试点。

Objective:The paper investigates the problems in the use of medical insurance funds in tertiary public hospitals,and puts forward suggestions on the use and supervision of hospital medical insurance funds.Methods:The feedback data of the medical insurance flight inspection in 2021 were reviewed and analyzed,and the problems were analyzed based on the literature and interview results.Results:It was found that repeated charges,charges exceeding the standard,drugs beyond the medical insurance payment scope,and substitution of items accounted for the highest proportion of medical insurance violations.According to the reason analysis,the violations were divided into profit-seeking behavior,inefficient behavior and deviation behavior.Conclusions:It is recommended to improve relevant laws and regulations and establish relevant systems,dynamically monitor violations and report them in time,strengthen the construction of a talent team and enhance the compatibility of medical insurance policies.Medical institutions should carry out the pilot reform of medical insurance physician system.