门诊共济保障机制下医保基金使用风险识别研究——以北京市某三甲医院为例

A Study on the Risk Identification of Medical Insurance Fund Use Under the Outpatient Mutual-aid Mechanism——Taking a First-class Hospital in Beijing as an Example

随着门诊共济保障机制不断完善,医保基金的覆盖范围和保障水平不断提高,欺诈骗保出现一些新情况,对医保基金安全运行构成威胁和挑战。本文以北京市某三甲医院2017年1月-2022年9月的门诊医保拒付数据为研究对象,运用专家函询、文献查阅、深度访谈等方法,初步构建门诊医保基金使用风险事件库。在此基础上,通过归因分析探讨门诊共济保障机制下欺诈骗保行为的动因,为医保基金精准监管奠定基础。

With the continuous improvement of the outpatient mutual-aid mechanism,the coverage and guarantee of the medical insurance fund is constantly expanding.However,at the same time there are new fraudulent behaviors of medical insurance funds,posing threats and challenges to the safe operation of medical insurance funds.This study is based on the outpatient cases which medical insurance refuses to pay for in a tertiary hospital in Beijing from January 2017 to September 2022,and applies expert consultation,literature review,and in-depth interviews to construct the risk event database for outpatient medical insurance funds.On this basis,attribution analysis is used to analyze the causes of medical insurance fraud,laying the foundation for precise regulation of medical insurance fund.